Human Factors in Aviation P S Ganapathy Consultant (Flight Ops.)

Human Factors in Aviation P S Ganapathy Consultant (Flight Ops.) Jet Airways (India) Ltd.

Human Factors in Aviation Background and Justification Importance of Safety Civil Aviation Safety Record Causes of Accidents What is Human Factor? Benefits of Human Factor Training

AVIATION INDUSTRY Technology based Employs 2 million people Generates US 2,40,000 million revenue Continuously growing Success and Survival solely depends on SAFETY

AVIATION SAFETY RECORD Quite impressive World wide accident rate of commercial large jet transport aircraft of the last three decades show a dramatic fall to 1.5 from 27 per million departures 616 million passengers travel on US carriers in 1988 with no fatalities 1987-1996 (a decade) 600 Airlines had no accidents at all

HULL LOSS--World Wide Jet Fleet Accidents by Primary Cause (%) Causes1988-97 1990-99 Human 70.5 67.5 Airplane 10.0 11.0 Weather 5.0 7.5 Maintenance 6.0 6.0 Airport/ATC 3.0 4.0 Misc 5.5 4.0 Total 100.0 100.0

HULL LOSS and /or Fatal Accidents (By phase of Flight) (%) Phase 1988-97 1990-99 Taxi 8 8 Take off 16 14 Climb 12 13 Cruise 9 6 Descent 2 5 Approach 17 13 Landing 36 41 5% flight time accounts for 60% of the accidents

MAJOR AREAS OF ACCIDENTS Type 1990-97 Push back 38 Hit by vehicle CFIT 47 Landing RTO % Change 46 21 20 36 -23 126 20 1989-99 157 25 14 -30 29 45

WHAT ARE THE LESSONS LEARNED? Human Factor emphasis is paying Dividend at a slow pace Greater awareness has contributed to the reduction in CFIT Technology continues to play a major role in accident prevention Safety is a cost effective tool

NEED FOR SAFETY ENHANCEMENT Human error continues to dominate as the cause of aviation accidents (65 to 70 %) Since 1970 the accident rate is relatively constant As the number of flight departures increase, we can anticipate an increase in the absolute number of accidents. Society does not understand the accident rates and is only concerned with the number of accidents irrespective of any decline in the global rates

Accident investigation reports The crew reacted prematurely and in a way deviated from the laid down procedure Series of distractions and aggravations in the cockpit The failure of the pilots to monitor flight instruments Flight crews’ failure to use check list Lack of team work amongst crew members

Human factors & Flight safety How can we prevent accidents? Examination of Industry’s accident investigation reports clearly establishes that different management of available resources could have prevented the accidents in majority of the cases

What are the available resources? Aircraft systems Procedure Manuals and check lists Cockpit crew Flight Despatchers Cabin crew Maintenance personnel ATC

What is Management? It is the coordinated use of the available resources to reach a goal Set the goal Evaluate risk Set the priorities Allocate resources Evaluate results

Development of Aviation Safety 1960 - 1980 Lonesome Heroes (Pilot Error) 1980- 1990 Crew Resource Management (Synergy) 1990-1999 Systemic Year (Organisation Dimension) WHAT IS IN STORE FROM 2000 ONWARDS?

What is CRM? The effective utilization of all available resources to achieve safe and efficient operation a flight Focus of CRM training is on the functioning of the crew as an intact team, not simply as a collection of technically competent individuals CRM aims at improving crew performance of

Human Factors HF is the Social Movement of learning the limit of human ability and movement and performance, to analyse and apply the knowledge gained to the daily operations to in prevent Human Failure which is the major source of accidents Aviation

What is Human Factor ? Concerns with Optimizing the Relationship between People and their Activities by Systematic Application of Human Sciences Integrated with System Engineering. It is about PEOPLE ; It is about PEOPLE in their Working Environment and it is about their Relationship with Machines and Procedures.

PROGRESS ON THE HUMAN FACTORS FRONT ICAO Since 1990, holding regular global flight safety and human factors symposium to bring in awareness. Incorporation of the requirement of human factors / CRM training and in accident / incident investigation in applicable annexes Regulatory authorities Inclusion of human factors training as mandatory in the training curriculum

PROGRESS ON THE HUMAN FACTORS FRONT Airlines Imparting CRM Training to Operation personnel emphasizing the significance of human factors for enhanced performance Aircraft manufacturers Human limitations are taken into consideration in the design of the system / layout

What is Human Factor Training ? Not a substitute for Technical Training Training directed to bring in CHANGE in Mindset Attitude Culture of Individual for enhancement of Safety and Efficiency

Focus of Human Factors Training Aviation Physiology Aviation Psychology Relationship- SHEL Model

Human Factors Training Develops the INDIVIDUAL for Decision Making Effective Communication Leadership Interpersonal Skills Good Resource Management Handling of Stress Teamwork

SHEL MODEL LIVEWARE {Human}is Centre Piece Live ware - Software Live ware - Hardware Live ware - Environment Live ware - Live ware

SHEL MODEL Live ware – Hardware Interface Relationship between Human & Machine Work station Configuration Display and Control Design Seats

SHEL MODEL Live ware – Software Interface Relationship between Individual and Supporting Systems . Regulations Manuals Check Lists Standard Operating Procedures

SHEL MODEL Live ware – Environment Interface Relationship between Individual and the Internal & External Environment Work area Temperature / Light / Noise / Physical Environment Outside the Work area. Weather, Terrain, Infrastructure, etc.

SHEL MODEL Live ware – Live ware Interface Relationship of individual with others in the Work area Cockpit crew,Maintenance & cabin crew Flight Dispatcher, Ground Support Regulators Management

FLIGHT CREW AREAS OF WEAKNESS 30% 20% 45% 5% ACTIVE FAILURE Non adherence to SOP Law violations / Lack of Vigilance Lack of Resource Management PASSIVE FAILURE Misunderstanding, Distraction Complacency, Forgetfulness PROFICIENCY FAILURE Inappropriate handling of A/C Misjudgment, Lack of Training MISCELLANEOUS

MAINTENANCE CREW WEAK AREAS 56% OMISSIONS 30% INCORRECT INSTALLATION 8% INCORRECT PART 6% MISCELLANEOUS

THOUGHT PATTERNS HAZARDOUS Replace ATTITUDE With ANTIDOTE ANTI AUTHORITY: – “Don’t tell me.” “Follow the rules. They are usually right.” IMPULSIVITY: “Do something- quickly.” INVULNERABILITY: “It won’t happen to me.” “Not so fast. Think first.” “It could happen to me.” MACHO: “I can do it.” “Taking chances is foolish.” RESIGNATION: “What’s the use?” “I’m not helpless. I can make a difference.”

WHAT ARE THE NEW TOOLS TO PREVENT ACCIDENTS? Traditional reactive approach has to be replaced by proactive approach to reduce human error. Encourage confidential non-punitive reporting system Identify and eliminate adverse trends with the effective use of DFDR to stop accidents before they happen AUDIT OF THE SAFETY MATRIX

WHAT CAUSES ACTIVE FAILURES? N E G L I G E N C E 14 5 7 12 9 7 5 14 3 5 81 E G O 5 7 15 27 I N C A P A C I T Y 9 14 3 1 16 1 3 9 20 25 101 209 leads to HU MAN E R R O R 8 21 13 1 14 5 18 18 15 !8 AC C I D E N T S 1 3 3 9 4 5 14 20 19 131 78 209

WHAT IS THE SOLUTION? INDIVIDUAL ATTITUDINAL CHANGE TO DO THINGS IN THE CORRECT MANNER AT THE FIRST INSTANT AS LAID DOWN IN THE MANUAL SENSE OF PRIDE TRUE MOTIVATION AND COMMITMENT

REACTIVE APPROACH to PROACTIVE APPROACH Flight Operation Quality Assurance Voluntary Incident Reporting System Regular Safety Audit Creating Safety Data Base and Trend Analysis

NON-PUNITIVE INCIDENT REPORTING SYSTEMS Air Safety Reports Confidential Reports Surveys

STATISTICS (PER MILLION DEPARTURES) Country Australia USA & Canada Europe Middle East Far East South East South America Africa Accident Rate 0.2 0.5 0.9 2.3 2.6 3.0 5.7 13.0 THIS SHOWS “CULTURE” HAS AN INFLUENCE ON AVIATION SAFETY

CULTURAL INFLUENCES ON AVIATI0N SAFETY Attitude towards errors Willingness to admit mistakes Reporting if things are wrong Keeping head down and not saying anything Independent thinking and questioning

Error, Performance and Safety Errors cause aircraft accidents Distinguish between errors and violation Error: Results when action deviates from intention; it is not intentional Violation: Results due intentional deviation from regulation or SOP; Initially intentional but can become routine

Consequences of errors Consequences of an error may be very different. Therefore we must clearly differentiate between an error and its consequences Best example: Difference between an error made in the simulator and the exact same error made in the air. Errors can be detected in a tolerant system and corrected; behaviour is re-adopted.

Call the colours Red blue yellow green blue yellow green red yellow green red blue green red blue yellow red blue yellow red yellow green blue yellow blue green red yellow blue

Error chain reaction With time,errors produce more and more negative effects create conditions for new errors contribute to accidents. Surrounding environment can turn a simple error into disaster.

Error Management Prevention Do not exceed your skills Set your priorities, manage your time and workload Learn from your errors; keep to the facts; do not listen to your ego. Work as a team Use checklists, callouts, cross checks Adherence to SOP

Update of situational awareness Anticipate the future Refer to past experience Attend to one subject at a time

Effective Communication Needs INQUIRY ADVOCACY LISTENING CONFLICT RESOLUTION CRITIQUE

What is Inquiry ? Information Seeking – Most Important Visual Scan Seeking Clarification from members Overcoming the Sensitive EGO

What is Advocacy ? ABILITY TO STATE WHAT YOU KNOW OR BELIEVEIN A FORTHRIGHT POSITION HOLDING TO YOUR VIEW POINT UNTIL IT IS PROVED BY FACTS, NOT BY AUTHORITY THAT IT IS WRONG

What is Listening? Active Listening is key to communication Requires active ATTENTION Listen MORE and Speak LESS

CONFLICT Advocating own position Becomes destructive if the argument is over who is RIGHT rather than what is RIGHT Arguments have a serious effect on the quality of the decision Not necessarily bad as long as they pertain to safety and efficiency

How to resolve Conflict? Have a policy of coordination that is known and acceptable to every one When disagreement arises, keep the discussion only on the issues needing resolution Bring all issues of disagreement Acknowledge and express all feelings that are deep enough to cloud your thinking

Conflict Resolution Key to the highest level of problem solving Leads to deeper thinking, creative to new ideas Promotes mutual respect Provides an opportunity to seek better solutions

Problem Solving Process Recognizes the problem Gathering of information of the problem Defining the problem based on the available facts Formulates solutions Applies the best available solutions Evaluates the results Reformulate if necessary

Barriers to communication Uncommunicative attitudes Hierarchy Body language conflicting with words High workload Different cultures Different mother tongue Noise, heat, cold Stress

How to improve communication? Crew members should Introduce themselves Use professional and friendly language Expect and give feed back Report anything you feel is a threat to safety Captain should set the tone for cockpit-cabin communication Share general expectations and address flight specific issues

LEADERSHIP QUALITIES Listening Emotional Stability Appreciation Decision Making Ethics Responsibility Sensitivity Humor Image Professional Competence

INTERPERSONNEL SKILLS Demonstrate openness to suggestions and change Provide and accept feedback Ensure team members to freely state opinion and participate in discussion Promote good relationship Makes the first contact a “ Magical’ ONE

PERSONALITY & ATTITUDE Direct bearing on Decision Making Personality is Resistant to CHANGE Attitude is amenable to CHANGE

Followership Qualities Advocacy Assertiveness Inquiry FAA definition-“Followership is the willingness to co-operate with respect for authority and subordination of personal preferences”

Human Capital R E A L P O W E R (18 5 1 12) (16 15 23 5 18) 113 (36) (77) is S Y N E R G Y (19 25 14 5 18 7 25 ) 113

TEAMWORK LEADS TO SAFETY Develop R E L A T I O N S 18 5 12 1 20 9 15 14 19 113 to create S Y N E R G Y 19 25 14 5 18 7 25 N I L 113 leading to I N C I DE NT (14 19 12) (9 14 3 9 4 5 14 20) 113

REMEMBER FOR TASK ACHIEVEMENT Tell me and I will Forget Show me and I will Remember INVOLVE me and I will UNDERSTAND

STRESS Body’s nonspecific response to demands placed upon it, whether demands are pleasant or unpleasant. Chronic (Result of long term demands by life events both positive and negative) Acute (From demands placed on the body by the task on hand) Fatigue,Illness and emotions are some STRESSORS involved in flying

Coping with stress Say that you feel stressed Recognise stress symptoms in others Allocate tasks Prioritise objectives Stick to documented task sharing Try a joke Never give up

Crew decision making 47% of the fatal accidents involve crew judgement and decision making (NTSB, 1994) Dealing with decision is dealing with safety Some decisions can be very bad Making no decision can be bad also

Some decision attitudes Hurry up: got to get there Invulnerability: this will not happen to me I know what it is, it has happened to me already I know I was right. I have done it hundred times before I am the boss and here is my decision That is the way we do it here ATC said ,“Expedite”, we must expedite

How to make better decisions Assess the problem and manage work load Evaluate risk and time pressure Set objectives and priorities Adopt response speed Use all available resources Refer to available procedures Consider non-obvious implications of decisions Manage time, buy time

SAFETY IS A SHARED RESPONSIBILITY F L I GHT S AF ET Y 6 12 9 7 8 20 19 1 6 5 20 25 138 is a J O I N T E F F O R T 10 15 9 14 20 5 6 6 15 18 20 138

ANSWER TO THE CHALLENGES OF AIR SAFETY IN THE NEW MILLENNIUM Attitude to be positive Non stop vigilance Situational awareness Willingness to learn Excellent communication Resource development