human factors management + checklists = safety

Federal AviationAdministration

Tampa FSDO FAASTeam

HUMAN FACTORS MANAGEMENT

+ CHECKLISTS = SAFETY

Presented to: Carrabelle Flying Club (X13)

Presented by: Bruce A. Graham

Date: 22 Aug 2020


WELCOME• Exits

• Restrooms

• Emergency Evacuation

• Breaks

• Sponsor Acknowledgment

• Set phones and pagers to silent or off

• Other information

– Social Distancing 6+ ft

– Masks if you desire

2


Agenda

• What Are “Human Factors” in Aviation

– Review and Discuss

– Understand the Role They Play

– “The Dirty Dozen”

• Risk Mitigation Checklists

– Types

– How to use them

– Role they play in mitigating Human Factors Issues

3


Importance of Human Factors

• Greatest impact in aircraft safety not from tech

• Educating personnel - recognize & prevent human error

• Approx 75–80% of aviation accidents due to human error

• 12% - maintenance related

• Pilot/co-pilot errors have immed / highly visible effects

• Maint errors more latent and less obvious, but can be just

as lethal.

4


HUMAN FACTORS FAILURE

5

• NTSB Aviation Accident Final Report

• NORTHWEST FLT 255

• Location: ROMULUS, MI

• Accident Number: DCA87MA046

• Date & Time: 08/16/1987, 2045 EDT

• Registration: N312RC

• Aircraft: MCDONNELL DOUGLAS DC-9-82

• Aircraft Damage: Destroyed

• Defining Event:

• Injuries: 156 Fatal, 2 Serious, 4 Minor

• Flight Conducted Under: Part 121: Air Carrier - Scheduled


NTSB FINDINGS

Occurrence #1: IN FLIGHT COLLISION WITH OBJECT

Phase of Operation: TAKEOFF - INITIAL CLIMB

Findings

1. PREFLIGHT PLANNING/PREPARATION - IMPROPER - PILOT IN COMMAND

2. (C) CHECKLIST - NOT PERFORMED - PILOT IN COMMAND

3. INATTENTIVE - PILOT IN COMMAND

4. DIVERTED ATTENTION - COPILOT/SECOND PILOT

5. (C) LOWERING OF FLAPS - NOT PERFORMED - COPILOT/SECOND PILOT

6. (C) LOWERING OF SLATS - NOT PERFORMED - COPILOT/SECOND PILOT

7. (F) WARNING SYSTEM(OTHER) - DISABLED

----------

Occurrence #2: IN FLIGHT COLLISION WITH TERRAIN/WATER

Phase of Operation: TAKEOFF - INITIAL CLIMB

6


HUMAN FACTORS

7

•Pilot’s Handbook of Aeronautical Knowledge, FAA-H-

8083-25B -

“Human factors. A multidisciplinary field encompassing the

behavioral and social sciences, engineering, and physiology,

to consider the variables that influence individual and crew

performance for the purpose of optimizing human performance

and reducing errors.”


8


Human Error In Aviation

• Human action with unintended consequences

• Nothing inherently wrong or troublesome with error itself

• But… error + aviation w/neg consequences very

troublesome

• Training, (boring FAAST stuff) risk assessments, safety

reviews, etc.,

– Not to restricted to attempt to avoid errors but make them visible and

identify before damaging and regrettable consequences.

– Human error is not avoidable but it is manageable

9


Safety awareness will help foresee and mitigate the risk of

human error

10


Types of Errors• Unintentional

– Unintentional wandering or deviation from accuracy

– Slip or mistake

• Missing a checklist item

• Missing a radio call

• Dialing wrong freq in radio

– Not intentional but an error nonetheless

• Intentional

– Should be considered a violation

– Knowingly or intentionally choose to do something wrong

– It is a violation, which means that one has KNOWINGLY deviated

from safe practices, procedures, standards, or regulations

11


THE DIRTY DOZEN• People make mistakes because they are people

• Error and success result from the same mental processes

so we cannot experience one without the other

• Since aviation is terribly unforgiving of human error, we

cannot afford to allow mistakes to “escape” and erode the

safety of our system

• Gordon DuPont (Transport Canada developed the “The

Dirty Dozen”)

• 12 preconditions for unsafe acts

• Focused on AMT but also applicable to “stick & rudder”

12


THE DIRTY DOZEN

• Complacency

• Distraction

• Pressure

• Lack of Resources

• Lack of Knowledge

• Awareness

• Stress

• Fatigue

• Communications

• Lack of Assertiveness

• Lack of Teamwork

• Norms

13

Things that influence people to make mistakes:


THE DIRTY DOZEN1. COMPLACENCY

– Always follow the checklist

– Never work from memory

– Never assume, always verify

– Be aware of the dangers of complacency

2. DISTRACTION

– Use an “approved” check list

– Always complete the checklist

– Double check the action (say it, do it

check it)

14


THE DIRTY DOZEN3. PRESSURE

• STOP! assess the situation, “get there / home i’tis”

• LOOK at the situation rationally: a. Can I safely perform the requested maneuver?

b. Have I voiced my concerns clearly?

c. What is the worst thing that can happen to me?

• LISTEN to your rational mind! a. Has this happened before?

• ACT Speak up, ask for help or time

– Ask for deviation

– Declare an emergency

15


THE DIRTY DOZEN4. LACK OF RESOURCES

– Current Publications

– Up-to-date data bases

– Required aircraft equipment

– Maintain aircraft to the highest Std, if in doubt cancel

5. LACK OF KNOWLEDGE

– Am I qual’d for this mission?

– Research / Study sources for a new arr /dep procedures,

new airfield, major airfield, remote field, etc

– Obtain school / sim training on new type, and model

– Use current manuals, old won’t cut it! (New 56 day cycle for Sect!)

16


THE DIRTY DOZEN

6. LACK OF AWARENESS– THINK ... what could occur in the event of an accident

– CHECK ... NOTAMS, WX, TFR, local FBO, other pilots

– ASK ... Someone to look at your flight planning or if you missed anything

see if anyone else can spot a problem you overlooked

7. STRESS– If you don’t manage stress, it will manage YOU!

– STOP - burning up emotional energy

– LOOK - rationally at the problem

– LISTEN - to your rational, not emotional mind

– ACT - once you have a plan, do it !

– If in doubt, step back, regroup and relax!

17


THE DIRTY DOZEN8. FATIGUE

– Bodies normal reaction to physical / mental stress of a prolonged duration

– Two Types:

• ACUTE ... short duration, cured with good nights sleep

• CHRONIC ... occurs over a period long period of time, long recovery!

– Causes

• Long hours of labor (any type) / Stress of high intensity / Large temperature variations

/ Noise ... above 80 db for long duration / Vibration for long periods and sufficient

intensity / STRONG lighting

– Symptoms

• Enhanced stimulus required in order to respond / Attention reduced / Memory

diminished / Mood becomes withdrawn / Circadian Rhythm (time of day effect)

18


THE DIRTY DOZEN9. COMMUNICATIONS

“ I have to tell you that what you heard and what I said

are two different things and what you think I said is

definitively not what I meant @*~<!!!”…from and ATC

controller near you…..

• “Learn to Listen”

– Don’t : Debate / Detour / Pre-Plan / Tune-out

– Do : Ask questions / Confirm / Read back / When in doubt, “say

again”

19


THE DIRTY DOZEN

10. LACK OF ASSERTIVENESS– Defined - “being disposed to or characterized by bold or confident assertions”

– By definition, most aviators are assertive, but comes with more experience

– You are the PIC, you are responsible for the “SAFE” conduct of the flight

– If you don’t like it, or are concerned, do not accept it….

– Record your decision and your rationale, you may need it later…

– Refuse to compromise your standards

– If you see something wrong or unsafe, speak up, IT could be your life you save!!!

20


THE DIRTY DOZEN

11. LACK OF TEAMWORK

– Always plan and discuss the WHO, WHAT, WHEN, WHERE, and HOW

of the flight / job

– Insure that everyone understands WHO, WHAT, WHEN, WHERE,

and HOW of the flight / job to be done

– Insure that everyone understands and agrees!

– Crew Coordination starts before the flight

• Make sure all crew & PAX have a role to play and make sure they understand

• Child - pet entertainment / support / pass the snacks / hold the pubs/

read the checklists / monitor bags / emerg procedures

21


THE DIRTY DOZEN12. NORMS

– “We have always done it that way…” does not make it right!

– Now it is a “NORM”

– ALWAYS work IAW documented procedures, the POH or approved

pubs

– If you disagree, work on getting it changed

– That is what your NTSB investigator will be looking at!!!

– Be aware that “NORMS” don’t make it right!

22


Risk Mitigating Checklists

• Types

– 5Ps Check

– Perceive, Process, Perform (3P) Model

– PAVE Checklist

– CARE Checklist

– TEAM Checklist

• How to use them

• Role they play in mitigating Human Factors Issues

23

Neil's Left Glove with sewn-on Cuff Checklist


RISK / Checklists

• Aeronautical Decision-Making (ADM) –

– Critical to safe operation of acrft & accident avoidance

• Crew Resource Management (CRM) -

– Training flight crews focused on effect use of all avail resources

• Human, hardware and info facilitate crew coop & improve decision-making

• Risk Management

1. Accept no unnecessary risk

2. Make risk decisions at the appropriate level

3. Accept risk when benefits outweigh dangers (costs)

4. Integrate Risk Management into planning at all levels

24


RISK / Checklists

• 5 Hazardous Attitudes / Antidotes

1. Anti-Authority: ”Don’t Tell me / Follow the rules, they are usually right

2. Impulsivity: “Do it quickly” / Not so fast, think first

3. Invulnerability: “It won’t happen to me” / It could happen to me

4. Macho: “I can do it” / Taking chances is foolish

5. Resignation: “What’s the use”/ I’m not helpless. I can make a difference

25


RISK / Checklists

• CRM vs. SRM

– Single-Pilot Resource Management (SRM)

• How to gather info, analyze it, & and make decisions

– The 5Ps Check

• The Plan / the Plane / the Pilot / the Passengers / the Programming

• Used to evaluate current situation at key points of flight or emerg

• Key Points incl:

– Preflight / pre-takeoff / hourly or mid flt / pre-descent / pre-FAF or for VFR

prior to traffic pattern entry

26


RISK / Checklists

• Perceive, Process, Perform (3P) Model

– Simple, practical, and systematic approach that can be used

during all phases of flight. To use it, the pilot will:

• Perceive the given set of circumstances for a flight

• Process by evaluating their impact on flight safety

• Perform by implementing the best course of action

– Use the Perceive, Process, Perform, and Evaluate method as

a continuous model for every aeronautical decision

– Evaluate the outcome, do it again…again till safely on deck

27


RISK / Checklists

• PAVE Checklist: Identify Hazards and Personal Minimums

• Perceive the Hazard

– Perceive the hazards during preflight planning, Risks of flight in 4

cat:

• P = Pilot in Command (PIC) - “Am I ready for this trip?” experience, recency,

currency, physical, and emotional condition. IMSAFE checklist provides the

answers.

• A = Aircraft - limitations upon trip? Right acft for this flight / familiarity with this

acft & currency / acft equip / acft performance

• V = enVironment – Weather / terrain / airport / airspace / nighttime

• E = External Pressures – external influences to make the flight, “get-there-it is”

single most important risk, can cause pilot to overlook all others

28


RISK / Checklists

• CARE Checklist: Review Hazards and Evaluate Risks

• Process info to determine risk/ impact if not controlled

or eliminated

– Consequences—departing after a full workday creates fatigue and

pressure

– Alternatives—delay until morning; reschedule meeting; drive

– Reality —dangers and distractions of fatigue could lead to an accident

– External pressures—business meeting at destination might influence me

29


RISK / Checklists

• TEAM Checklist: Choose and Implement Risk Controls

• Perform risk management by using the TEAM checklist

– Transfer—Should this risk decision be transferred to someone else

(e.g., do you need to consult the chief flight instructor?)

– Eliminate—Is there a way to eliminate the hazard?

– Accept—Do the benefits of accepting risk outweigh the costs?

– Mitigate—What can you do to mitigate the risk?

• Perform action to eliminate hazards or mitigate risk, and

continuously evaluate the outcome to resolution

30


SUMMARY• HUMAN FACTORS MANAGEMENT + CHECKLISTS = SAFETY

– We focused on helping the pilots improve their ADM skills with the

goal of mitigating the risk factors associated flight

– “In the end, the discussion is not so much about aircraft, but about

the people who fly them.”

– https://www.faa.gov/regulations_policies/handbooks_manuals/aviati

on/phak/media/04_phak_ch2.pdf

31

https://www.faa.gov/regulations_policies/handbooks_manuals/aviation/phak/media/04_phak_ch2.pdf


Acknowledgement and Sources

• Pilot’s Handbook of Aeronautical Knowledge, FAA-H-8083-25B – Chapt. 2

• “Human Factors of Flight-Deck Checklists: The Normal Checklist” Asaf Degani, San

Jose State University, Foundation; San Jose, CA; Earl L. Wiener, University of Miami

Coral Gables, FL; Prepared for Ames Research Center May 1990; National

Aeronautics and Space Administration, Ames Research Center, Moffett Field, CA

• AMT Human Factors Handbook Addendum;

https://www.faasafety.gov/files/gslac/courses/content/258/1097/AMT_Handbook_Ad

dendum_Human_Factors.pdf

• “Human Factors Issues of the Aircraft Checklist,” Patrick Ross, Winter 2004; Embry-

Riddle Aeronautical University

32

https://www.faasafety.gov/files/gslac/courses/content/258/1097/AMT_Handbook_Addendum_Human_Factors.pdf


Acknowledgement and Sources• “Human Factors for Aviation Maintenance,” FAA Airworthiness Safety Seminars, “Putting

“yoU” In Human Factors !!!” presented by Lou Lerda; Safety Program Manager with the

Seattle Flight Standards District Office

33


Questions?

• Bruce Graham, FAASTeam Representative

– Apalachicola Regional Airport (KAAF)

& Carrabelle-Thompson Airport (X13)

– [email protected]

– Cell: (703) 678-6042

• Andrew Crossman, FAASTeam Program Manager

– Aviation Safety Inspector

– Tampa Flight Standards District Office

– [email protected]

– Office #: 813-287-4933

34


Proficiency and Peace of Mind

35

• Fly regularly with your CFI

• Perfect Practice

• Document in WINGS


Thank you for attending

• You are vital members of our GA safety

community

36


Tampa FSDO FAASTeam

HUMAN FACTORS MANAGEMENT

+ CHECKLISTS = SAFETY

Presented to: Carrabelle Flying Club (X13)

Presented by: Bruce A. Graham

Date: 22 Aug 2020

human factors management + checklists = safety

Documents