categorizing human performance hazards for safety ... · [email protected] 678.777.3873...
TRANSCRIPT
Dr. Bill Johnson
Chief Scientific and Technical Advisor
Maintenance Human Factors
678.777.3873
Federal AviationAdministration
Categorizing Human Performance
Hazards for Safety Management
Systems
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Presentation Plan
• HF Challenges in Flt. Operations?
• SMS to the Rescue?
• PEAR : A way to consider HF Hazards
• New Thoughts and Actions
• Q&A
Top 10 Challenges - ALL
Category Name % Vote # Score
Culture/Leadership 24 524
Tech Documentation 16 356
Fatigue 11 248
Voluntary Reporting 6 134
ROI 5 120
HF Training 5 108
Pressure/Stress 4 99
Oversight & Regulations 4 95
Professionalism 3 64
Other 3 61
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Presentation Plan
• HF Challenges in Flt. Operations?
• SMS to the Rescue?
• PEAR : A way to consider HF Hazards
• New Thoughts and Actions
• Q&A
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Safety Management Systems Should:
Formalize data collection
Prompt deeper root cause analysis
Identify hazards and opportunities for continuing safety
Keep a focus on human factors. (PEAR) Measure HF!
Allocate new resources to HF hazards
Show how HF interventions return the investment(Safety & Money)
Federal AviationAdministration
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Presentation Plan
• HF Challenges in Flt. Operations?
• SMS to the Rescue?
• PEAR : A way to consider HF Hazards
• New Thoughts and Actions
• Q&A
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People who perform the job
Environment for work - Organizational and physical
Actions (tasks) performed as part of the job
Resources like equipment, tools, procedures, and more
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Physiological
Health
Nutrition
Lifestyle
Alertness/fatigue
Chemical dependency
Physical
Size
Gender
Age
Strength
The five senses
Psychological
Experience
Knowledge
Training
Attitude
Emotional state
Psychosocial
Interpersonal relations
Ability to communicate
Empathy
Leadership
People — Example factors
Ryanair 737-800 (September, 2005)
B-737 made three un-stabilized approaches, in thunder storms, to separate Italian airports. Final landing was saved by low-time 1st Officer.
Captain did not report that infant son had died that week.
A320-200 at Perpignan, France (November 2008)
• Pilots from XL Airways and Air New Zealand
• XL was returning A/C after 2 year lease
• Acceptance check ride
• Did not adhere to pre-agreed flight schedule
• Did not reserve airspace for necessary testing
• 2 of 3 AOA sensors were inop due to improper cleaning
• Crew were not trained for acceptance test missions.
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Charlotte, NC: Air Midwest Flight 5481, Jan 2003
Resource Issues: technical documentation, training, personnel
resources, busy schedules, fatigue training
Additional Information
Following 100 Hr. Inspection
Fore/aft Servo was replaced
Post maintenance check flight flown
2 revenue tour flights flown
Flight time since maintenance was 3.5 hours
Cause
35
The main rotor fore/aft servo flight control
input rod was not connected.
Bolt, washer, locking nut, and cotter pin
were missing.
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Presentation Plan
• HF Challenges in Flt. Operations?
• SMS to the Rescue?
• PEAR : A way to consider HF Hazards
• New Thoughts and Actions
• Q&A
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Compliance Philosophy ?
“…. When deviations from regulatory standards do occur, the FAA’s goal is to use the most effective means to return an individual or entity…..to full compliance and to prevent recurrence.
….FAA recognizes that some deviations arise fromfactors such as flawed procedures, simple mistakes,lack of understanding, or diminished skills. The agencybelieves that deviations of this nature can mosteffectively be corrected root cause analysis andtraining, education or other appropriateimprovements to procedures……”
FAA Order 8000.373, June, ‘15
Federal AviationAdministration
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Compliance Philosophy for Inspectors
FAA Order 8900.323.
“…the Aircraft Flight Standards approach to oversight and compliance is evolving to stress an engaged, solution-oriented, outcomes-based approach. The goal is to identify deviations from standards and correct them as effectively, quickly, and efficiently as possible….This approach will more effectively address inadvertent deviations and conserve FAA enforcement for intentional, reckless, criminal, and uncooperative behavior.
...Accordingly, AFS leaders, managers, and supervisors will support inspectors when they use critical thinking to exercise sound professional judgment and take actions in accordance with this notice.”
Federal AviationAdministration
• Not unanimous but without blame
• Panel includes: Mgmt., Labor, and FAA
• No-Nos are: (Criminal Activity, drugs/alcohol, intentional falsification)
• See FAA AC120-66B
Aviation Safety Action Program (ASAP)
• Formalized Voluntary Reporting System