Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
FAA HUMAN FACTOR IN AVIATION MAINTENANCE HF MROAmnat Sk
This manual is in response to the industry’s requests for a simple and manageable list of actions to implement a Maintenance Human Factors (MHF) program. A panel of experts selected the following six topics for such a program to be successful:
Event Investigation
Documentation
Human Factors Training
Shift/Task Turnover
Fatigue Management
Sustaining & Justifying an HF Program
For each of the six topics that contribute to the success of any MHF program, this manual offers the following:
Why is the topic important?
How do you implement it?
How do you know it is working?
Key references
Like any good operator’s manual, this document tells you what to do without excessive description of why you should do it. This manual recognizes you already know the importance of Human Factors. For detailed information, see the “Key References” at the end of each topic.
The selected six topics are critical because they are based on operational data and practical experience from the US and other countries. Transport Canada (TC), United Kingdom Civil Aviation Authority (UK CAA), and the European Aviation Safety Agency (EASA) regulations contributed to this manual. The steps are derived from a panel of ten industry and government contributors who have worked in aviation maintenance for an average of twenty-five years and in MHF for fifteen years. The contributors characterized these six topics and related steps as “information they wish they had known 15 years ago.”
These straightforward suggestions provide the key components for implementing a successful MHF program that will benefit your company, business partners, external customers, and the entire industry. Information is presented in summary bullets as follows:
These are six topics, from many, that a MHF program may consider.
Topics are not necessarily in order of importance, except that the data obtained from Event Investigation (Section 1) provide the foundation for many Human Factors activities.
You may implement any or all of the topics, however, they should be coordinated.
Your MHF activity should be based on the identified requirements and resources of your organization.
You are encouraged to supplement this Operator's Manual with additional references.
This document satisfies the industry request for a short and straightforward list of important actions.
Insights from David Alexander ICAO AVSEC Pm and General Manager: AVSEC at Professional Aviation Security on current aviation security challenges including recent airport attacks and providing some possible practical solutions
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FAA HUMAN FACTOR IN AVIATION MAINTENANCE HF MROAmnat Sk
This manual is in response to the industry’s requests for a simple and manageable list of actions to implement a Maintenance Human Factors (MHF) program. A panel of experts selected the following six topics for such a program to be successful:
Event Investigation
Documentation
Human Factors Training
Shift/Task Turnover
Fatigue Management
Sustaining & Justifying an HF Program
For each of the six topics that contribute to the success of any MHF program, this manual offers the following:
Why is the topic important?
How do you implement it?
How do you know it is working?
Key references
Like any good operator’s manual, this document tells you what to do without excessive description of why you should do it. This manual recognizes you already know the importance of Human Factors. For detailed information, see the “Key References” at the end of each topic.
The selected six topics are critical because they are based on operational data and practical experience from the US and other countries. Transport Canada (TC), United Kingdom Civil Aviation Authority (UK CAA), and the European Aviation Safety Agency (EASA) regulations contributed to this manual. The steps are derived from a panel of ten industry and government contributors who have worked in aviation maintenance for an average of twenty-five years and in MHF for fifteen years. The contributors characterized these six topics and related steps as “information they wish they had known 15 years ago.”
These straightforward suggestions provide the key components for implementing a successful MHF program that will benefit your company, business partners, external customers, and the entire industry. Information is presented in summary bullets as follows:
These are six topics, from many, that a MHF program may consider.
Topics are not necessarily in order of importance, except that the data obtained from Event Investigation (Section 1) provide the foundation for many Human Factors activities.
You may implement any or all of the topics, however, they should be coordinated.
Your MHF activity should be based on the identified requirements and resources of your organization.
You are encouraged to supplement this Operator's Manual with additional references.
This document satisfies the industry request for a short and straightforward list of important actions.
Insights from David Alexander ICAO AVSEC Pm and General Manager: AVSEC at Professional Aviation Security on current aviation security challenges including recent airport attacks and providing some possible practical solutions
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What Do You Do When The Pilots Shut Down The Wrong Engine?Bob Mayer
And the other engine is the one that is malfunctioning? Yes. It happened. This slideshow presents the sequence of events and the six cascades that led to the final crash. Mechanical failure, pilot error, and more all contributed to this event.
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And the other engine is the one that is malfunctioning? Yes. It happened. This slideshow presents the sequence of events and the six cascades that led to the final crash. Mechanical failure, pilot error, and more all contributed to this event.
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.
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Sustainability has become an increasingly critical topic as the world recognizes the need to protect our planet and its resources for future generations. Sustainability means meeting our current needs without compromising the ability of future generations to meet theirs. It involves long-term planning and consideration of the consequences of our actions. The goal is to create strategies that ensure the long-term viability of People, Planet, and Profit.
Leading companies such as Nike, Toyota, and Siemens are prioritizing sustainable innovation in their business models, setting an example for others to follow. In this Sustainability training presentation, you will learn key concepts, principles, and practices of sustainability applicable across industries. This training aims to create awareness and educate employees, senior executives, consultants, and other key stakeholders, including investors, policymakers, and supply chain partners, on the importance and implementation of sustainability.
LEARNING OBJECTIVES
1. Develop a comprehensive understanding of the fundamental principles and concepts that form the foundation of sustainability within corporate environments.
2. Explore the sustainability implementation model, focusing on effective measures and reporting strategies to track and communicate sustainability efforts.
3. Identify and define best practices and critical success factors essential for achieving sustainability goals within organizations.
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1. Introduction and Key Concepts of Sustainability
2. Principles and Practices of Sustainability
3. Measures and Reporting in Sustainability
4. Sustainability Implementation & Best Practices
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Startle effect in aviation-MULTIPLE FAILURES- Management of flight
1. ESQUEMA DE TRABAJO
• DIA DE VUELO: FCOM, QRH, MOA,
FPPM, RAAC, COD AER, COD PENAL,
etc, etc, etc –
• El barra brava
2. MODELO AR RESOLUCIÓN DE FALLAS. MIX BOIEING-AIRBUS
(GOLDEN RULES) Y EXTRACTO DEL FCTM DE LOS 5 PUNTOS.
• MAX x2 –Air France,
etc…
• No se LOGRO SALIR
DEL ITEM #1 DE LA
FASE DE CONTENCION.
4. YA PASARON 10 AÑOS
On 1 June 2009, an Airbus A330-200 operated by Air France on a
scheduled passenger flight from Rio de Janeiro to Paris CDG as
AF447 exited controlled flight and crashed into the sea with
the loss of the aircraft and all 228 occupants.
It was found that the loss of control followed an
inappropriate response by the flight crew to
a transient loss of airspeed indications in the cruise which resulted
from the vulnerability of the pitot heads to ice crystal icing.
6. A320, en-route Karimata Strait IndonesiA(On 28 December 2014, an
A320 crew took unapproved action in response to a
repeating system caution shortly after levelling at FL320.
The unexpected consequences degraded the flight control
system and obliged manual control.
Gross mishandling followed which led to a stall, descent
at a high rate and sea surface impact with a 20º pitch attitude and a
50º angle of attack four minutes later.
7. HACER LO QUE NO HAY QUE HACER Y
NO HACER LO QUE HAY QUE HACER
The Investigation noted the accident origin as a repetitive minor
system fault but demonstrated that the subsequent loss of
control followed a combination of explicitly inappropriate
pilot action and the absence of appropriate pilot
action.
8. MAS EVENTOS RELACIONADOS
UPS B763 near Goose Bay on Feb 7th 2019, multiple system failures
Sunwing B38M near Washington on Nov 14th 2018, multiple system failures
American B763 over Atlantic on Feb 16th 2018, multiple system failures
Flybe DH8D near Manchester on Oct 23rd 2013, multiple electrical system failures
Air Canada E190 near Toronto on Jun 8th 2011, multiple system failures
Compass E170 at Saskatoon on Dec 20th 2010, slat and multiple system failures
British Airways B772 near Amsterdam on Jun 15th 2010, multiple technical problems
Air Canada A319 near Winnipeg on Sep 7th 2008, multiple system failures
Canada A333 at Toronto on Feb 20th 2019, multiple system faults
India B773 Sep 11th 2018, multiple instruments including localizer receivers lost
UTAir Cargo AN74 near Kupol on Dec 1st 2018, multiple problems
Canada Rouge A319 Dec 2nd 2018, multiple ECAM messages
13. ?POR QUE CREEN QUE NO SE ESTÁN PUDIENDO CONTENER
TANTAS FALLAS COMPLEJAS QUE CADA VEZ SE REPITEN MAS?
?POR QUE NO HACEN EN LA SITUACIÓN CRÍTICA LO QUE NOSOTROS
ANALIZAMOS ACÁ EN TRANQUILIDAD MATE POR MEDIO?
NO SABEN
NO PUEDEN
NO QUIEREN
16. ….”I’m one of the relatively small group of people who have experienced
such a sudden crisis – and lived to share what we learned about it. I can
tell you firsthand that the startle factor is real and it is huge
– it interferes with one’s ability to quickly analyze the crisis and take
effective action.
17. STARTLE EFFECT IN AVIATION
• DEFINICION
• DESCRIPCION
• FREEZE
• CONSECUENCIAS
• CONTENCION Y MITIGACION
18. DEFINICION
El susto, sobresalto o reacción de alarma es una respuesta de la
mente y del cuerpo a un estímulo repentino e inesperado.
19. UN POCO MAS ELABORADO
In aviation, startle effect can be defined as an uncontrollable,
automatic reflex that is elicited (provocado, obtienido) by exposure to
a sudden, intense event that “violates a pilot’s expectations.”
the "fight or flight" réflex
20. ?QUE PODEMOS HACER FRENTE A UNA RESPUESTA
FISIOLÓGICA, AUTOMATICA Y NO CONTROLABLE?
Modelo Cognitivo/Conductual
Entrenamiento, práctica sistemática y repetitiva (respuesta
condicionada)
Exposición gradual a estímulos desencadenantes, etc.
EN AVIACION: Teoría y práctica. Entrenamiento, Exposición y
Simulación.
21. ?CUANDO SE DESENCADENA EL S.E.?
Frente a estímulos intensos, repentinos y NO ESPERADOS.
FACTOR SORPRESA (Entrenamiento/perfil guía vs FS)
22. DESCRIPCION
El SE incluye ambas respuestas tanto la física como la mental.
• Depende de un evento repentino y no esperado.
Se lo define como un estado AGUDO. (Intensidad/Tiempo)
24. RESPUESTA FISIOLOGICA
• Cardiovascular System: Heart rate increases, blood pressure rises and
coronary arteries dilate to increase the blood supply to brain, limbs and
muscles
• Respiratory System: Depth and rate of breathing increases providing
more oxygen to the body
• Endocrine System: Liver releases additional sugar for energy. Adrenal
glands release adrenalin
• Muscular System: Muscles tense in readiness for immediate action
• Excretory System: Sweat production increases
• Nervous System: Brain activity changes, reactions become less
reasoned and more instinctive.
25. RESPUESTA MENTAL/EMOCIONAL
MENTAL:
• El procesamiento consciente y la decodificación de la información puede
volverse mucho mas lenta o anularse.
• La capacidad de analizar una situación y tomar acciones correctivas
puede verse seriamente limitada o directamente INCAPACITADA por la
intensidad de la respuesta fisiológica.
FREEZE
En aviación hay procedimiento de emergencia para esto:
PILOT INCAPACITATION FCTM/MOA
26. RESPUESTA EMOCIONAL Y MENTAL
Serio deterioro de la Respuesta motora a tareas simples.
En tareas complejas llega a una interrupción de las acciones
necesarias frente a una tarea dada de hasta 10 segundos.
(FREEZE)
Posible deterioro cognitivo irreversible en un periodo (se anulo)
27. STARTLE EFFECT STATEMENTS
• Startle has been found to impair information processing performance on
mundane tasks, such as the continuous solving of basic arithmetic problems, for
30 to 60 seconds after the event occurrence. (nos dejo perturbados)
• The duration of the performance degradation increases as the task becomes
more complex. (COMO DEDICIR EN UN VUELO)
• Thus, the startle effect disrupts cognitive processing and can negatively
influence an individual’s decision making and problem solving abilities.
28. APLICACIÓN PRACTICA Y EFECTIVA:
Como Instructores/Inspectores/Formadores/Facilitadores, que
podríamos hacer cuando vemos que un alumno se “freezo” o está con una
incapacidad moderada por estar sobrepasado?
?Como podemos como INST-IP contribuir a fortalecer, enseñar y entrenar a
los alumnos para mitigar los efectos del SE?
?Es enseñable y entrenable? O es a suerte y verdad…
SE ANULO
SE FUE
LO PERDIMOS
29. SIEMPRE ANDA TODO BIEN Y NUNCA
PASA NADA,…HASTA QUE PASA
El SE si ha potenciado en los últimos años por la:
1. ALTA CONFIABILIDAD EN LAS AERONAVES
2. MUY BAJA OCURRENCIA DE FALLAS
3. ALTO NIVEL DE AUTOMATIZACION
4. MUY BAJA EXPECTATIVA DE QUE ALGO PUEDE PASAR
30. CONSECUENCIAS
"… one of the common themes as aircraft become more reliable is
that pilots are surprised or startled by some event and
as a result have either taken no action or alternatively taken
the wrong action, which has created an undesired aircraft state
or an accident.
31. EXPECTATIVA VS FACTOR SORPRESA
The problem then is the level of expectation of critical events is so
low that the level of surprise or startle which pilots encounter
during such events is higher than they would perhaps have had
some decades ago when things went routinely wrong.
FUNCION INVERSA BAJA: EXPECTATIVA-/EVENTO+=ALTO SE
32. EN UN PASADO, DEBIAMOS SER
CREATIVOS Y PROACTIVOS
Un día típico años atrás…:
Planes de vuelo de baja exactitud, baja disponibilidad de
información (MET X HF).
Múltiples MEL (APU INOP, START VALVE MANUAL, ETC)
MOTORES INTERMIX y Flight Decks distintos a un mismo modelo
NO AP (Solo CWS y Alt HOLD) NO FMC (GPS con suerte)
MENOR ALCANCE EN DISTANCIA Y ALTITUD
NO IRS, NO TCAS, NO ACARS, NO EFB, NO CPDLC, WX RADAR
VERDE (alcance 100NM), NECESIDAD DE HF, ADF, etc, etc,…
33. EVENTOS QUE NOS EXPONEN AL SE
• IMPACTO CON AVES EN EL DESPEGUE
(US AIRWAYS) Tuvieron que negociar por el SE 4 o 5 segundos (SE, shock,
negación, reacción, análisis, toma de decisiones) para que no los juzguen
basados en la NO respuesta inmediata.
• EXPLOSION
• UPSET O PERDIDA DE CONTROL SUBITA
• FALLAS MULTIPLES (AF447, SOUTHWEST, LYON, etcx100)
• FALLA COMPLEJAS SIN NNC NNP (beyond the scope NNC)
• CUALQUIER EVENTO INESPERADO Y CON POTENCIAL DE
ACCIDENTE.
34. IMPACTO OPERATIVO DEL SE
• PERIODO DE DESORIENTACION, NEGACION Y CONFUSION
• LIMITACION PSICOMOTORA SEVERA-FREEZE (interrupción de
las tareas)
• Degradación en la CALIDAD de acciones requeridas para el vuelo.
• Deterioro cognitivo y limitación en la habilidad de toma de
decisiones.
• Tiempo requerido para la recomposición psicológica y anímica
desde el estímulo.
35. CONTENCION Y MITIGACION
Researchers have identified a number of strategies that can reduce
the negative effects of startle and help improve pilot performance
during and immediately following a startle event.
FAA
Flight Safety Foundation
DGAC´s Regionales (Australia, etc)
EASA (ver Estudio/Investigación SE Management)
36. PLAN DE ACCIONES CONCRETAS
ANALISIS GRUPAL
• SINTESIS: De la teoría a la práctica
• AUTODIAGNOSTICO DE LAS RECOMENDACIONES (?Estamos
familiarizados con las siguientes medidas?)
• COMO PODEMOS APLICARLAS A LA ACTIVIDAD DE INSTRUCCION
• SINTESIS DE TODAS LAS INVESTIGACIONES HASTA LA FECHA.
38. EN TODA SITUACION
EL CONOCIMIENTO ES
DECISIVO
He Knew The System So Well.
He Found The Solution,
He Activated The Solution,
Under Extreme Circumstances…
IT WAS MY LUCKY DAY TO BE FLYING
WITH HIM
39. 1) KNOW YOUR AIRCRAFT
Develop a sound technical knowledge of your aircraft type and
maintain it with regular revisión. (Ver nota Boeing)
• PITCH VS N1
• VALORES DE REFERENCIA
• CONOCIMIENTO DE LOS SISTEMAS, NP, NNP, ETC…
• EL PODER DEL CONOCIMINETO.
40. 2) MANTAIN HANDLING SKILL
Be competent and comfortable flying the aircraft "without the
automation“
PRACTICA Y ENTRENAMIENTO
“ The children of MAGENTA”
41. 3) TRAINING
Simulator exercises should be conducted in a constructive manner
with a focus on #evidence based (most likely) events.
However, there should also be constructive use of unexpected
critical events.
Ver GESTION FALLAS COMPLEJAS/MULTIPLES
• #Evidencia: fallas complejas o múltiples es lo que esta pasando.
42. 4) BE AWARE OF YOUR
SURROUNDINGS
Develop and maintain effective situational awareness skill-sets.
The Pilot Monitoring (PM) should actively monitor the Pilot Flying
(PF) and both should actively monitor the aircraft automation.
MET/CAT/ICING
MEA-MORA-TERRAIN
OTHER TRAFFICS
FL OPT/ MNV MARGIN
44. 5) AVOID COMPLACENCY
Have a healthy expectation and suspicion for things going wrong.
(Si nunca pasa nada…)
Recordemos: BE/ESTIMULO=SE+/-
BE: Baja Expectativa
SE: Startle Effect de mayor o menor magnitud
47. 7) HAVE A PLAN AT ALL TIMES
Mentally rehearse or foster crew discussion of a "plan of action" for
both common non-normal events, and for the rare, "out of the
ordinary" events such as ditching, upset or uncontrollable fire.
BRIEFING Y PLANIFICACION EFECTIVA
Adopt a "what would I do if.." mindset
48. LA PLANIFICACION ES LA CLAVE
No tendrá las mismas consecuencias una situación con alto potencial
de STARTLE EFFECT si el evento ocurre:
A una tripulación debidamente entrenada,
Disciplinada con una cabina ordenada,
Que utiliza en forma efectiva los SOP´s,
Que es consciente de su entorno,
Que planifica y monitorea el desarrollo del vuelo
49. CHECKLIST
1. KNOW YOUR AIRCRAFT
2. MANTAIN HANDLING SKILLS
3. TRAINING
4. BEWARE OF YOUR SURROUNDINGS
5. AVOID COMPLACENCY
6. ANTICIPATE THREATS
7. PLAN, PLAN, PLAN
50. EN CAPACITACIÓN Y SEGURIDAD
"You can either pay now... or pay later.“
53. STATEMENT #1
LO QUE ESPERA LA INDUSTRIA
Pilots must be able to handle an unexpected emergency and still keep their passengers
and crew safe
EN REPRESENTACION DE LOS PILOTOS Y USUARIOS
But we should first design aircraft for them to fly that do not have inadvertent traps set
for them.
Nota: Nuestra matriz de instrucción es todo “expected”…PERO LA INDUSTRIA ASUME
UNA CAPACIDAD Y HABILIDAD NO INSTRUIDA, NI ENTRENADA.
54. #STATEMENT 2
These two accidents, as well as Air France 447 which crashed in the South Atlantic in June 2009, are also vivid illustrations of the
growing level of interconnectedness of devices in aircraft. Previously, with older aircraft designs, there were mostly stand-alone
devices, in which a fault or failure was limited to a single device that could quickly be determined to be faulty and the fault remain
isolated. But with integrated cockpits and data being shared and used by many devices, a single fault or failure can now have rapidly
cascading effects through multiple systems, causing multiple cockpit alarms, cautions and warnings, which can cause distraction and
increase workload, creating a situation that can quickly become ambiguous, confusing and overwhelming, making it much harder to
analyze and solve the problem.
STATEMENT OF CHESLEY B. “SULLY” SULLENBERGER III
Subcommittee on Aviation
of the
The United States House Committee on Transportation and Infrastructure
June 19, 2019
55. SINGLE VS MULTIPLE FAULTS
growing level of interconnectedness of devices
stand-alone devices- fault remains isolated --NO MAS--
single fault or failure can now have rapidly cascading effects through
multiple systems
ambiguous, confusing and overwhelming, making it much harder to
analyze and solve the problem.
57. NO LO VIMOS VENIR
UPS B763 near Goose Bay on Feb 7th 2019, multiple system failures
Sunwing B38M near Washington on Nov 14th 2018, multiple system failures
American B763 over Atlantic on Feb 16th 2018, multiple system failures
Flybe DH8D near Manchester on Oct 23rd 2013, multiple electrical system failures
Air Canada E190 near Toronto on Jun 8th 2011, multiple system failures
Compass E170 at Saskatoon on Dec 20th 2010, slat and multiple system failures
British Airways B772 near Amsterdam on Jun 15th 2010, multiple technical problems
Air Canada A319 near Winnipeg on Sep 7th 2008, multiple system failures
Canada A333 at Toronto on Feb 20th 2019, multiple system faults
India B773 Sep 11th 2018, multiple instruments including localizer receivers lost
UTAir Cargo AN74 near Kupol on Dec 1st 2018, multiple problems
Canada Rouge A319 Dec 2nd 2018, multiple ECAM messages
64. NOTA BOEING
• En el Turno 2 del Recurrent del 2do Semestre, una de las situaciones a entrenar es el exceso de temperatura
en cabina y su lista asociada “Cabin Temperature Hot”.
• Una de las situaciones posibles que plantea la lista es tener que despresurizar la cabina estando por encima
de 10000 ft, situación que produciría la activación de la CABIN ALTITUDE WARNING, la cual ordena cerrar la
outflow VALVE, contradiciendo a la lista anterior.
• Compartimos la respuesta de Boeing en relación a esta inquietud planteada por un Inspector de la Flota.
• “When step 19 of the Cabin Temperature Hot NNC directs the crew to descend to the lowest safe altitude or
10,000 ft, whichever is higher, the crew should immediately follow the route's contingency plan for high terrain
escape during depressurization.
• The second choice of step 31 directs the crew to don oxygen masks, followed by shutting off the operating
pack in step 32, then opening the outflow valve in the subsequent steps to increase airplane ventilation
followed by landing at the nearest suitable airport. We expect a crew to have sufficient system knowledge
and situational awareness to realize that they are depressurizing and to not close the outflow valve
if there is a CABIN ALTITUDE warning, unless unpressurized flight at high altitude presents a greater threat
than the high cabin temperature.
• In all situations, the Captain must assess the situation and use good judgment to determine the safest
course of action.”
65. “SUPUESTOS BOIENG”
TODOS CONTENIDOS EN LA FO
1) System Knowledge: ITEM #1 de las estrategias de mitigación del SE
2) Situtational Awarness: ITEM#4 ídem
3) La oración refiere implícitamente al sentido común, el cual se aprende y entrena
con el uso de la Filosofía Operativa (8 horas)
4) Must assess the situation: Thinking fast slow, Toma de decisions, Capacidad para
resolver problemas complejos, Trabajo bajo presión, Gestión del Stress, Liderazgo.
MO-A “criterios para resolver problemas inesperados o no documentados”
5) Use good judgment…PODEMOS HABLAR UN AÑO, pero idem 3. El Estudio de la
filosofía operativa en forma exhaustiva canaliza y casi anula los errores de este tipo.
Ya comenzamos
6) Determine the safest course of action: Como evaluar de forma racional que es
mas y menos Seguro? Enseñamos a tomar el curso de accion MAS SEGURO? No
un curso de accion Seguro, Boeing pide “the safest” no “ a safe..”
65
66. • ¿ESTAMOS ENFOCANDONOS EN ESO??
• SISTEMATICAMENTE FRENTE A TODO PROBLEMA TECNICO O
DE OPERACIÓN BOEING SIEMPRE RECRRE A LA FILOSOFIA
OPERATIVA COMO RESPUESTA, y ningún procedimiento o mejor
dicho todos los procedimientos están diseñados con esos 50
principios pero no son del todo explicados para cuando hay
situaciones, fuera del estándar, ambiguas o complejas.
68. TODOS SOMOS PILOTOS DE PRUEBA
• ANALIZAR EL ARTICULO
• https://www.propilotmag.com/operational/
• Estamos entrenados para eso?
• El piloto promedio STD que vuela la línea magenta como debe ser,
dentro de la envolvente, tiene entrenamiento adecuado para esto??
69. UN PUNTO SOBRE EL
ENTRENAMIENTO ADECUADO
• https://www.aerotime.aero/clement.charpentreau/23726-af447-air-france-sent-back-to-
court-case-dismissed-for-airbus?utm_source=newsletter&utm_medium=email
• https://www.theguardian.com/world/2019/jul/17/air-france-could-face-trial-over-2009-
crash-of-rio-paris-flight
• LA MORALEJA ES QUE FRENTE A TODO REQUERIMIENTO TECNICO LOS
FABRICANTES se basan en que la filosofía operativa todo lo explica (y es verdad)
pero no la enseñamos ni la entrenamos en forma regular ni formal.
• Por otro lado cuando el problema se expone en los medios y murió gente… la justicia
recurre casi inequívocamente a FALLAS, OMISIONES O ERRORES EN LOS
PLANES DE ENTRENAMIENTO E INFORMACION Y FORMACION DE SUS
TRIPULACIONES.
• TENEMOS UN GRAN RECURSO EN NUESTRA MANOS.. LA INSTRUCCIÓN Y EL
CONTROL DE LA CALIDAD DE LA MISMA.
PIZZARRON DIBUJAR LINEA CON TODOS LOS MANUALES FILOSOFIA OPR Y POLICA OPR ATRAVIESA TODO. (UN CUADRITO QUE MARQUE DONDE ESTA EL PROGRAMADA DE GESTION DE FALLLAS MULTIPLES) ARRIBA DE TODO EN EL PIZZARRON UN PUNTITO QUE ES DONDE ESTAMOS. Y BREVE INTRO DEL AUTO DOMINIO DE INGENIERO PREMIO NOBEL A BARRA BRAVA EN UN SEGUNDO, EJEMPLO DEL PEAJE.
1- nos habilito al crm 2 los atr, Potomac, etc, nos habilito a la normativa de icing y las limitaciones hold over times, y el AF nos introdujo en una nueva etapa que ira modificando la forma de entrenamiento.
ALGUIEN LEYO LOS CONTENIDOS DE LA EXPOSICION DE SULLY FRENTE AL COMITÉ DEL SENADO? 19 DEL 06 2019, Alto contenido de sentido común.
TODO LOS LLEVA A ESTOS INTERROGANTES
TENERIFE HABILITO EL ENTRENAMIENTO EN CRM Y FFHH/ Los 3 o 4 ATR, Potomac, el 727 el fokker y demás, dieron a luz los temas de ICING, LIMITACIONES DE OPR EN ICING LA REGLA DE LOS 5 MINUTOS ETC, AIRFRANCE ABRIO LA PUERTA al estudio del startle effect y la fallas complejas e integradas.
Freeze, como se llama en aviación? PILOT INCAPACAITACION: ////NO ES UNA CLASE DE FFHH NI DE FISIONLOGIA, EL OBJETIVO ES QUE IDENTIFIQUEMOS EL PROBLEMA RAIZ QUE ESTA ANTES DE LA TOMA DE DECISIONES, QUE ES EL FACTOR SORPRESA Y COMO BENEFICIARNOS DE CONOCERLO PARA MEJORAR NUESTRAfuncion y rol de INSTRUCtores.
ACA YA SE VE EL PROBLEMA, RESPUESTA AUTOMATICA Y REFLEJA, CAJA DE PANDORA para gente no entrenda en la materia. Se dice que bajo presión extrema no se sabe como reaccionara uno, por eso lo CRITICAMENTE IMPORTANTE de entrenar en forma sistematica y repetitiva algunas maniobras , como RTO, …son por REFLEJO. RTO RECONOCIMIENTO-DECISION –Y EJECUCION EN 2 SEGUNDOS. SULLY NEGOCIO 6 O 7 con dual eng flame out
Si bien no entrenamos factor sorpresa por que los perfiles son como un guion, en el LOFT habría una oportunidad estratégica.
Afecta la emocinalidad, estamos bajo una amenaza percibida inicialmente como de PELIGRO. Se nubla nuestra claridad mental por tanta adrenalina. SINO EL PREMIO NOVEL NO SE TORNARIA BARRA BRAVA EN EL PEAJE.
EJEMPLOS DE SIM BAJO PRESION EN IP FINALES, QUE POR UNA DISCREPANCIA EN LA PREFLIGHT O PUESTA EN MARCHA SE QUEDO AHÍ POR EL RESTO DEL TURNO, FIJACION.
Esto esta transcripto de estudios de las DGAC, son estudios sobre esta temática.
DEBATE-IDEAS
AMENAZA LA RUTINA-COMPLACENCIA-EL SIEMPRE VA TODO BIEN VS LO INESPERADO…Quien esta esperando que fallen los AOA/VELOCIMETROS EL TRIM HAGA UN RUNAWAY EN EL PRIMER DESPEGUE DE LAS 4 AM???
Ya vimos el ejemplo del asiana que al decidir y ejecutar mal se generaron una falla mas compleja (criterio de falla compleja y multiple autogenerada por error de ejecución)
FUENTES Y ORGANIZACIÓN DONDE SE VIENE ESTUDIANDO Y TRABAJANDO SOBRE ESTE FACTOR QUE AFECTA LA SEGURIDAD.
LO ANTERIOR FUE LA INTRO Y EL CONTEXTO, ESTE EL PUNTO PARA NOSOTROS COMO FORMADORES, AUTO EVALUARNOS EN COMO ESTAMOS CON ESTAS RECOMENDACIONES.
REFLEXION SOBRE NUESTRA CULTURA, DE QUE TODO ES EL PF, en las inspecciones, el evaluado siempre es el PF. DE a poco se va metiendo en la cultura el tema de la importancia del PM, ES EL TIPO QUE MAS VE POR QUE no esta absorvido por las tareas a rrealizar mas aun si es vuelo manual o con NNP.
NO creer que es un video juego, estar atentos.
RECALCAR LA IMPORTANCIA DE COMO LEENOS LISTAS NORMALES…. UNO LEE, UNO RESPONDE PERO DOS VERIFICAN!!!!!! EJEMPLO DE DIEGO
Briefing hecho por los dos a consciencia y en forma UTIL-operativa, no recitar el briefing de despegue o hablar sin escucharnos y verificar que estamos diciendo con la preparación de cabina., briefing puede haber durante todo el vuelo a medida que surgen sitauciones que requieren
ALGUIEN LEYO LOS CONTENIDOS DE LA EXPOSICION DE SULLY FRENTE AL COMITÉ DEL SENADO? 19 DEL 06 2019, Alto contenido de sentido común.