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Federal Aviation Administration 1 Human Factors for Part 135 Air Operators 23 February 2012 Presented to: Orlando FSDO Air Operator Safety Summit By: Janeen Kochan Date: 23 February 2012 Federal Aviation Administration Human Factors for Part 135 Air Operators Beyond Filling the Square

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Federal Aviation Administration 2 Human Factors for Part 135 Air Operators 23 February 2012 Human Factors and/or CRM Training? Who? Where? When?

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Federal Aviation Administration 3 Human Factors for Part 135 Air Operators 23 February 2012 Human Factors A multidisciplinary field devoted to optimizing human performance and reducing human eror. (OOOPS!)

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Federal Aviation Administration 4 Human Factors for Part 135 Air Operators 23 February 2012 Human Factors The study of human machine interaction in context

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Federal Aviation Administration 5 Human Factors for Part 135 Air Operators 23 February 2012 Ergonomics Designing the machine and task to fit the human (or not)

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Federal Aviation Administration 6 Human Factors for Part 135 Air Operators 23 February 2012 Quick CRM History 1940's - Military 1970's - Accident Studies/ ASRS 1980's - Pilot Judgment Training 1980's - Cockpit Resource Management 1990's - Crew Resource Management 2000's Threat & Error Management 2010's - Same Stuff, Different Day

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Federal Aviation Administration 7 Human Factors for Part 135 Air Operators 23 February 2012 Lack of Accidents Safety! 1 in 600

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Federal Aviation Administration 8 Human Factors for Part 135 Air Operators 23 February 2012 Margin of Safety vs. Accidents

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Federal Aviation Administration 9 Human Factors for Part 135 Air Operators 23 February 2012 The freedom from danger, risk, or injury. Safety

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Federal Aviation Administration 10 Human Factors for Part 135 Air Operators 23 February 2012 It Wont Happen To Me! WHEN ANYONE ASKS ME HOW I CAN BEST DESCRIBE MY EXPERIENCE IN NEARLY FORTY YEARS AT SEA, I MERELY SAY, UNEVENTFUL. OF COURSE THERE HAVE BEEN WINTER GALES, AND STORMS AND FOG AND THE LIKE, BUT IN ALL MY EXPERIENCE I HAVE NEVER BEEN IN AN ACCIDENT OF ANY SORT WORTH SPEAKING ABOUT. I HAVE SEEN BUT ONE VESSEL IN DISTRESS IN ALL MY YEARS AT SEA....I NEVER SAW A SHIPWRECK AND HAVE NEVER BEEN SHIPWRECKED, NOR WAS I EVER IN ANY PREDICAMENT THAT THREATENED TO END IN DISASTER OF ANY SORT.

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Federal Aviation Administration 11 Human Factors for Part 135 Air Operators 23 February 2012 It Wont Happen To Me! ON 14 APRIL 1912 RMS TITANIC SANK WITH THE LOSS OF 1500 LIVES - ONE OF WHICH WAS ITS CAPTAIN....... E.J. SMITH

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Federal Aviation Administration 12 Human Factors for Part 135 Air Operators 23 February 2012 It wont happen to meagain?

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Primary Causal Factors of Aircraft Accidents

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Federal Aviation Administration 14 Human Factors for Part 135 Air Operators 23 February 2012 CRM Requirement for Part 135 http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr&sid=4af131373951c80175d09d635 e196163&rgn=div8&view=text&node=14:3.0.1. 1.11.8.3.7&idno=14

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Federal Aviation Administration 15 Human Factors for Part 135 Air Operators 23 February 2012 CRM 135.330 Crew resource management training. (a) Each certificate holder must have an approved crew resource management training program that includes initial and recurrent training. The training program must include at least the following:

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Federal Aviation Administration 16 Human Factors for Part 135 Air Operators 23 February 2012 CRM (1)Authority of the pilot in command; (2) Communication processes, decisions, and coordination, to include communication with Air Traffic Control, personnel performing flight locating and other operational functions, and passengers; (3) Building and maintenance of a flight team;

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Federal Aviation Administration 17 Human Factors for Part 135 Air Operators 23 February 2012 CRM (4) Workload and time management; (5) Situational awareness; (6) Effects of fatigue on performance, avoidance strategies and countermeasures; (7) Effects of stress and stress reduction strategies; and (8) Aeronautical decision-making and judgment training tailored to the operator's flight operations and aviation environment.

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Federal Aviation Administration 18 Human Factors for Part 135 Air Operators 23 February 2012 CRM (b) After March 22, 2013, no certificate holder may use a person as a flightcrew member or flight attendant unless that person has completed approved crew resource management initial training with that certificate holder.

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Federal Aviation Administration 19 Human Factors for Part 135 Air Operators 23 February 2012 The Roach Theory of Errors Errors are like roaches... For every one you see...

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Federal Aviation Administration 20 Human Factors for Part 135 Air Operators 23 February 2012 Threat and Error Management (Dr. Robert Helmriech - U. of Texas) Studied crews (watched them) Looked at threats and errors Categorized types of threats and errors Analyzed events to learn from them

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Federal Aviation Administration 21 Human Factors for Part 135 Air Operators 23 February 2012 External Threats Expected Threats Forecast weather, terrain, fuel Unexpected Threats Mechanical problems, traffic, weather Latent Systemic Threats Accident waiting to happen We've always done it this way

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Federal Aviation Administration 22 Human Factors for Part 135 Air Operators 23 February 2012 What is Human Error? Action or inaction that leads to a deviation from yours or someone elses intentions or expectations.

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Federal Aviation Administration 23 Human Factors for Part 135 Air Operators 23 February 2012 Errors Are Like Roaches There are different species and sizes Slips - meant to do the right thing but took incorrect action Lapses - omitted an item Mistakes - intention was incorrect Intentional Non-Compliance - intentionally deviated from SOP or accepted procedure

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Federal Aviation Administration 24 Human Factors for Part 135 Air Operators 23 February 2012 Error Enhancers Fatigue/excessive stress Lack of oxygen/water/food Distractions/interruptions First learned, best learned Insufficient situation awareness Workload -too low or high

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Federal Aviation Administration 25 Human Factors for Part 135 Air Operators 23 February 2012 Human Errors Leading To Events... How many errors need to occur before we have an "event"?

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Federal Aviation Administration 26 Human Factors for Part 135 Air Operators 23 February 2012 What is an Event? The breaching, absence or bypassing of some or all of the aviation systems various defenses and safeguards.

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Federal Aviation Administration 27 Human Factors for Part 135 Air Operators 23 February 2012 Here's the cheese...

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Federal Aviation Administration 28 Human Factors for Part 135 Air Operators 23 February 2012 Human Responses to Errors Trap - error is detected and managed before it becomes consequential Exacerbate - error is detected but the individuals action or inaction becomes consequential Fail to Respond - lack of a response to an error (undetected or ignored) that can either end up being inconsequential or consequential

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Federal Aviation Administration 29 Human Factors for Part 135 Air Operators 23 February 2012 Error Management (aka) Roach Control Detection and recovery Understand and be vigilant for potential error enhancers Prevent as many as possible Oh Noooo...

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Federal Aviation Administration 30 Human Factors for Part 135 Air Operators 23 February 2012 Your Company Culture The set of shared attitudes, values, goals, and practices that characterizes an institution or organization The set of values, conventions, or social practices associated with a particular field, activity, or societal characteristic

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Federal Aviation Administration 31 Human Factors for Part 135 Air Operators 23 February 2012 Presented to: Orlando FSDO Air Operator Safety Summit By: Janeen Kochan Date: 23 February 2012 Federal Aviation Administration Human Factors for Air Operators Make Safety Your Culture