presented to: by: date: federal aviation administration the other things we must know! it’s all...

Presented to:

By:

Date:

Federal AviationAdministrationThe Other Things We

Must Know!

It’s All About The It’s All About The Safety……!Safety……!

Fred Harms

Federal AviationAdministration

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Safety is a balancing act

Cost vs. BenefitsCost vs. Benefits


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•ACCIDENTS

•INCIDENTS

•ERRORS AND UNREPORTED

OCCURRENCES

Accidents are only the tip of the iceberg!

For every accident there are 600 errors

and/or unreported

occurrences


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HUMAN FACTORS

• The term 'human error’– is used in recognition of the fact that most

aviation accidents do involve human error at some point in the chain of events.

– these errors (or unsafe acts) tend to be just one link in a chain of events.


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Human error is a symptom of trouble deeper inside the system.• Safety is NOT inherent in systems. People

have to create safety.

• Human error is connected to our tools, tasks and operating environment. Progress in safety comes from understanding and influencing these connections.


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•7


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Error, by any other name….• Complacency — the failure to recognize the

gravity of a situation or to adhere to standards of care or good practice.

• Non-compliance — the failure to follow rules or procedures that would keep the job safe.

• Loss of situation awareness — the failure to notice things that in hindsight turned out to be critical.


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3 Factors Leading to Human Error

1. Overload:Overload: is the imbalance between a person’s capacity (natural ability, training, state of mind), and added burdens resulting from environmental factors (noise), internal factors (stress) and situational factors (unclear instructions).

2. Inappropriate Response:Inappropriate Response: If a person detects a hazardous condition but does nothing to correct it, or if a person removes or fails to use a safeguard, it is an inappropriate response.

3. Inappropriate Activities:Inappropriate Activities: A person who undertakes a task that he/she does not know how to do or misjudges the degree of risk in a given task and proceeds based on the misjudgment.


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

anyway!”• “Although the weather was deteriorating,

the pilot pressed on.”


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Three factors in Intentional Non Compliance

1. Motivation (Reward)2. High Probability of Success3. Absence of Peer Pressure or Reaction

All three required, or intentional non-compliance does not occur.


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1. Task Design – design tasks with working memory capacity in mind

2. Equipment Design a) Minimize perceptual confusions – ease of

discrimination• Ex: airplane controls that feel like what they do (flaps, wheels)

b) Make consequences of action visible – immediate feedback

• Ex: choice box in some software programs

c) Lockouts – design to prevent wrong actions• Ex: car that will not let us lock door if the key is still in

d) Reminders – compensate for memory failures• Ex: ATM reminds us to take our card

Error Prevention / Mitigation


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3. Training – provide opportunity for mistakes in training, to learn from them

• Ex: Scenario-based training/evaluations

4. Assists and Rules – checklists to follow• Ex: Pilot pre-flight checklist

5. Error-tolerant systems – system allows for error correction or takes over when operator makes serious error

• Ex: Undo button in computer program

Error Prevention / Mitigation


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–Failure?Failure?–Mistake?Mistake?


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The Focus of Flight Training

• Assumption – risk assessment skills will emerge as part of the training experience.

• Reality – we are trained within a specific operational environment and our experience is relatively selective.

We have difficulty in accurately appraising our performance and anticipating hazards that we are likely to experience.


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The Great Lie• “When pilots fail to admit the risks, the

odds are they won’t do a good job of managing those risks.”

• “The vast majority of fatal accidents are caused by a failure in risk management, yet flight training is focused almost exclusively on skill.”

• “The answer is that instructors must teach, and pilots must learn a practical, proactive procedure to anticipate and manage risks.”

John King


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A CLOSED MIND TO RISK LEADS TO

ACCEPTANCE OF GREATER RISK.


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Pilot Responsibility

• Knowledge/skill maintenance

• Motivation

• Know and comply with the rules and the standards

• Evaluate and support a Safety Culture


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


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School/FBO Responsibility

• Viability – staying in business

• Training/education

• Operating policies

• Support a Safety Culture

• Comply with the rules and uphold the standards


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• Rote learning over cognitive – pass the check ride.

• Inner-generational blindness.

• Reactive day-to-day business management.

• Turn over rate high.

• Newness to the aviation System.

Flight Schools Face Unique Pressures


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The Social Environment1. Human behavior is influenced by our social

environmenta) Social norms, mgmt practices, morale, training,

incentives• e.g. construction workers will not wear safety gear if no one

else is


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FAA Responsibility

• Create and enforce rules and standards

• Verify training and performance

• Properly select DPE’s, and assign responsibilities

• Impart a safety culture


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ICAO Annex 6• “From 1 January, 2009,

States shall require, as part of their safety programme, that an operator implement a safety management system acceptable to the State of the Operator…”

• The U.S. has filed a difference with ICAO

• Currently, there are no FAA authorized procedures to accept or approve Service Providers’ SMS’s


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Development of a Safety Management System

The story-line may seem familiar!


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DPE Responsibility

• Knowledge

• Motivation

• Task design

• Support a Safety Culture

• Comply with the rules and uphold the standards


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CFI Responsibility

• Teach and comply with the rules and standards

• Training/education

• Motivation

• Task design

• Impart a Safety Culture


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


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Most pilots learn risk Most pilots learn risk management by trial management by trial and error.and error.

Flight instructors can Flight instructors can teach pilots specific teach pilots specific risk management risk management skills with skills with scenariosscenarios that require the pilot that require the pilot to use those skills.to use those skills.


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Considerations for Decision Making

• Pilots make improper decisions when they feel a pressure to go or continue.

• The safety culture or value system of any organization can influence how a pilot makes decisions.

• Completing a flight safely requires that every pilot develop a risk assessment and management plan, with personal minimums that are not compromised.


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Final Thoughts!• We can’t stop people from being human….so

let’s build an error tolerant system of checks and balances.

• If something goes wrong, you can count on second guessers who have the benefit of hind sight….SO


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Let’s Ask Ourselves These Questions….Will my decisions and actions be:

• Prudent?

• Reasonable by company standards?

• Consistent with best practices?

Bias to the conservative!


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Other Things We Must Know

Thank You For Attending

The Central Region FAA Safety Team (FAASTeam) is dedicated to Quality Customer Service and we would value your feedback. Please provide your feedback at:

www.faa.gov/about/office_org/headquarters_offices/avs/offices/afs/qms


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presented to: by: date: federal aviation administration the other things we must know! it’s all...

Documents

aviation accidents

human factors

human error overload

term human error

inappropriate response

internal factors

inappropriate activities

task design design tasks