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Aviation Safety Training
- 1. Presented to: By: Date: Federal Aviation AdministrationThe Other Things We Must Know! It’s All About TheIt’s All About The Safety……!Safety……! Fred Harms
- 3. Federal Aviation Administration 3 Safety is a balancing act Cost vs. Benefits Cost vs. Benefits
- 4. Federal Aviation Administration 4 •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
- 5. Federal Aviation Administration 5 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.
- 6. Federal Aviation Administration 6 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.
- 8. Federal Aviation Administration 8 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.
- 9. Federal Aviation Administration 9 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.
- 10. Federal Aviation Administration 10 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.”
- 11. Federal Aviation Administration 11 Three factors in Intentional Non Compliance 1. Motivation (Reward) 2. High Probability of Success 3. Absence of Peer Pressure or Reaction All three required, or intentional non- compliance does not occur.
- 12. Federal Aviation Administration 12 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) a) Make consequences of action visible – immediate feedback • Ex: choice box in some software programs a) Lockouts – design to prevent wrong actions • Ex: car that will not let us lock door if the key is still in a) Reminders – compensate for memory failures • Ex: ATM reminds us to take our card Error Prevention / Mitigation
- 13. Federal Aviation Administration 13 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 4. 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
- 15. Federal Aviation Administration 15 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.
- 16. Federal Aviation Administration 16 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
- 17. Federal Aviation Administration 17 A CLOSED MIND TO RISK LEADS TO ACCEPTANCE OF GREATER RISK.
- 18. Federal Aviation Administration 18 Pilot Responsibility • Knowledge/skill maintenance • Motivation • Know and comply with the rules and the standards • Evaluate and support a Safety Culture
- 19. Federal Aviation Administration 19 Prevention Strategies Recognize 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
- 20. Federal Aviation Administration 20 School/FBO Responsibility • Viability – staying in business • Training/education • Operating policies • Support a Safety Culture • Comply with the rules and uphold the standards
- 21. Federal Aviation Administration 21 • 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
- 22. Federal Aviation Administration 22 The Social Environment 1. Human behavior is influenced by our social environment a) Social norms, mgmt practices, morale, training, incentives • e.g. construction workers will not wear safety gear if no one else is
- 23. Federal Aviation Administration 23 FAA Responsibility • Create and enforce rules and standards • Verify training and performance • Properly select DPE’s, and assign responsibilities • Impart a safety culture
- 24. Federal Aviation Administration 24 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
- 25. Federal Aviation Administration 25 Development of a Safety Management System The story-line may seem familiar!
- 26. Federal Aviation Administration 26 DPE Responsibility • Knowledge • Motivation • Task design • Support a Safety Culture • Comply with the rules and uphold the standards
- 27. Federal Aviation Administration 27 CFI Responsibility • Teach and comply with the rules and standards • Training/education • Motivation • Task design • Impart a Safety Culture
- 28. Federal Aviation Administration 28 When pilots leave the supervisionWhen pilots leave the supervision of their instructor theof their instructor the accident rate goes upaccident rate goes up almost 50%!almost 50%!
- 29. Federal Aviation Administration 29 Most pilots learn riskMost pilots learn risk management by trialmanagement by trial and error.and error. Flight instructors canFlight instructors can teach pilots specificteach pilots specific risk managementrisk management skills withskills with scenariosscenarios that require the pilotthat require the pilot to use those skills.to use those skills.
- 30. Federal Aviation Administration 30 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.
- 31. Federal Aviation Administration 31 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
- 32. Federal Aviation Administration 32 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!
- 33. Federal Aviation Administration 33 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
Editor's Notes
- The decision of an entire airline to no longer accept NDB approaches (Non-Directional Beacon approaches to a runway, in which the aircraft has no vertical guidance and rather imprecise lateral guidance) (Collins, 2001) is one example; the reluctance of airlines and/or pilots to agree on LASHO—Land And Hold Short Operations—which put them at risk of traveling across an intersecting runway that is in use, is another. In resource-constrained systems, however, safety does not always prevail. RVSM (Reduced Vertical Separation Minima) for example, which will make aircraft fly closer together vertically, will be introduced and adhered to, mostly on the back of promises from isolated technical fixes that would make aircraft altitude holding and reporting more reliable. But at a systems level RVSM tightens coupling and reduces slack, contributing to the risk of interactive trouble, rapid deterioration and difficult recovery (Perrow, 1984).
- ICAO is a United Nations Organization that issues international standards related to civil aviation. It bases its authority on the Chicago Convention, an international treaty. As administrators of the treaty, ICAO’s standards have the weight of the treaty itself. Member states have agreed to abide by the ICAO Annexes, which deliver the standards as specific to the various components of the air transportation system (e.g. manufacturing, air traffic, airports, operations, licensing, etc.). Review slide in the context of: There is a lot of energy around the deadline for Member States to be complaint with Annex 6, and what that means for the US aviation industry. Recall that the ICAO requirement applies to “Member States,” not individual service providers. Here is the extract….notice the golden words….. Although the FAA does not have a regulation in place (to meet the Jan 1, 2009 deadline), the FAA has chartered an Aviation Rule-Making Committee (ARC), and the FAA is following its formal rulemaking process to consider an SMS rule. The FAA intends to comply with the ICAO requirement, but is unwilling to rush a formal process to produce a meaningless rule that doesn’t function for the Industry or the FAA. In the interim, Flight Standards is conducting SMS Voluntary Implementation Pilot Projects to develop experience for both the Industry and FAA.