Human factors in Aviation Seminar

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Human factors in AviationSeminar

• Captain Daniel P. Mahoney
• Master Certified Flight Instructor
• FAA Flight Safety Counselor

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Harold Harris, Vice PresidentPan American World
Airways, circa 1950

• Attention!
• Aircraft Designers, Operators, Airmen, Managers.
  Anxiety never disappears in a human being in an
  airplane.-it merely remains dormant when there is
  no cause to arouse it. Our challenge is to keep
  it dormant.
• Reference Human Factors in Aviation
• Earl L. Wiener and David C. Nagel

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Captain Jim SiffordPiedmont AirlinesTo a class
of new hire pilots, circa 1978

• We pay you not to make mistakes!

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A Definition of Human Factors

• Human factors (or ergonomics) may be defined as
  the technology concerned to optimize the
  relationships between people and their activities
  by the systematic application of the human
  sciences, integrated within a framework of system
  engineering.

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Water Ditching

• Left Over From Last Seminar
• Airline F/A announcement
• Your seat cushions can be used for flotation
  and, in the event of an emergency water landing,
  please paddle to shore and take them with our
  compliments

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The SHEL Model

• HARDWARE
• Buildings
• Vehicles
• equipment

• SOFTWARE
• Rules
• Regulations
• Laws
• SOPs

• LIVEWARE
• Human Beings

• ENVIRONMENTAL
• Hostile physical environment?

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The L-H Interface

• The lines joining the system components
  represent the interfaces through which energy and
  information are exchanged.
• LIVEWARE-HARDWARE
• Example
• Pilot setting the engine power over the range of
  operation
• The engineers must create the facilities (gauges
  or glass instruments) for the pilot to operate
  the engine

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LIVEWARE-SOFTWARE

• Software must not be in conflict with human
  characteristics it is futile to formulate rules
  with which conformity cannot be attained and
  unwise to formulate them such that undue
  difficulty is generated.
• Example Investigate if the rules rather than
  the violators are basically at fault.

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LIVEWARE-ENVIRONMENTAL

• Hostile physical environment-temperature,
  radiation, air pressure, weather etc.
• A matter of devising ways to protect crews and
  passengers from discomfort and damage by using
  pressurized cabins, thermal insulation, and the
  like.

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System Stability

• Any changes within a SHEL system may have
  far-reaching repercussions. A minor equipment
  modification (change in H), for example, needs
  examination in relation to its interfaces with
  operators and maintenance personnel (
  readjust L-H) it may necessitate procedural
  changes ( readjustment of S) and hence some
  further training programs (to optimize L-S).
  Unless all such potential effects of change are
  properly pursued, it is possible for a
  comparatively small modification in a system
  component to lead to highly undesirable and
  dangerous consequences

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Tasks that require procedures

• Pre-flight and Checklist usage
• Taxi-runway incursion
• Briefing-takeoff, climb, cruise, approach, missed
  approach etc
• Altitude Awareness
• Automation management
• Cockpit Resource Management
• Single Pilot Cockpit Res.
• Management

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Standard Operating Procedures

• Pilot Operating Handbook
• Checklists
• Airmen's information manual
• Your own good operating practices that you follow
  by habit but are not written down

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Food for Thought

• Write your own SOP for your plane
• It might include details for minimum and
  maximums for example
• Weather briefings or personal minimums
• Maximum flight durations
• Night Flying etc

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PINC

• ACCIDENTS caused by PINC
• Procedural Intentional Non-Compliance
• Business and Commercial Aviation, January 2006
  Author David Huntzinger

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Gulfstream 3 March 2001

• According to the NTSB, the crash of the G3 at
  Aspen, Co., the crew began the approach knowing
  the landing would occur after official sunset,
  which was specifically prohibited on the approach
  plates. When the crew reached Minimum Descent
  Altitude they continued the approach without
  visual references to the runway

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Pacific Northwest

• A commercial pilot was flying a float-plane
  heading up a channel with rising terrain on both
  sides and a cloud deck above him. Its a VFR
  flight with passengers and cargo. Before
  committing to the channel, the pilot told himself
  he could always turn around if the situation
  deteriorated. But then the channel narrowed and
  the ceilings lowered more than he anticipated.
  Coming around a corner, he was alarmed to see a
  bridge dead ahead, its deck solidly buried in the
  cloud

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Falcon 20

• A German freight operation with a Falcon 20 was
  contracted to haul cargo from Poland to the US.
  The crew began the mission in Western Europe,
  flew to Poland, picked up the stuff, went to
  Iceland, refueled and then headed for Greenland
  for a night NDB/DME approach. On the outbound leg
  of the approach, they spotted the field, broke
  off and went visual. The F-20 crashed 4 miles
  from the airport killing all three pilots. The
  crew had been awake for 22 hours, on duty for 17
  and had 9.4 hours in flight in violation of
  German duty limits of 14 hours.

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Three Elements of PINC

• Motivation-reward if you violate the rules
• Situational Assessment- what are my risks
• Adverse Reaction- it is unlikely my action will
  produce any adverse reaction from my peers

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Eliminate any One

• The elimination of any one of the three factors
  will shut down the PINC and save the operation

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Another F/A announcement

• After a less than perfect landing, We ask you to
  remain seated while Captain Kangaroo bounces us
  to the terminal

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Analyze This

• This first accident is recent and a reflection of
  the most basic point to be made. Although HF
  studies can seem a little complicated, think of
  this old favorite.

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Eclipse 500

• Sept 3. Just before noon an E-500 ( new and under
  development and testing- test pilot at the
  controls- should be a good pilot, no?) was
  substantially damaged when it landed gear up at
  ABQ. The 500 was returning from a local test
  flight.
• Pilot he was downwind for RW 3, the tower asked
  him to fly a short approach.

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continued

• The pilot deviated from his normal checklist
  habit pattern and he admitted he forgot to lower
  the landing gear.

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• PINC?
• What procedure could he have used assuming you
  agree it was ok to help the tower by expediting?

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GUMP?

• Gas
• Undercarriage
• Mixture
• Pumps
• This old favorite is not completely applicable to
  a jet but will cover you none the less.

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Young Eagles Rally

• October 15, 2005 PA28 was destroyed due to impact
  with trees/terrain near Paine field Washington.
  VFR conditions. The aircraft was performing a
  go-around at the time of the landing event
  organizers said the aircraft was scheduled to
  land at PAE to allow the two Young Eagles to
  exchange seats.

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Reported from witnesses and reports from the site

• Skidded on the left side of the approach end of
  RW 16L, a second skid mark 20 feet later ( and 10
  more feet to the left) in the grass. F-2 taxiway
  sign had two posts broken.
• Then it departed at a very low altitude and
  approximately 7000 feet down runway it topped 2-
  80 foot trees, and the wreckage came to rest 35
  feet beyond the trees, consumed by fire.

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No conclusions at this point

• What procedures if any could have been applied to
  help avoid this accident. This is only
  speculation and we dont presume to know the
  cause. It may never be known.
• Do you see any ADM factors here? Lets discuss
  this.

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Habit Patterns that should be honored

• Could poor crosswind technique landed the pilot
  too far left of the centerline?
• Should a go around have been initiated sooner
  rather than later. Perhaps a damaged prop
  inhibited the planes ability to climb to a safe
  altitude.
• Do we ever discuss aborted maneuvers in GA?

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Some ideas for us

• Critique ourselves after every flight.
• I need more practice on cross wind landings?
• Brief ourselves more often. ie Land on the
  centerline in the touchdown zone
• In the event of a GA, full power, positive pitch
  attitude, retract half of the flaps.

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• WAS THIS A PINC accident?

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My Opinion

• DONT THINK SO!

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US AIRWAYS F/A

• The next time you get the insane urge to go
  blasting through the skies in a pressurized metal
  tube, we hope youll think of US Airways.

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PA-32R-301Friday July 16, 1999

• N9253N
• Cause per NTSB The pilots failure to maintain
  control of the airplane during a descent over
  water at night, which was a result of spatial
  disorientation. Factors in the accident were
  haze, and the dark night.
• Who are we talking about?

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Some interesting Notes

• 310 hours total time-not too shabby
• 55 hours of night time-not too shabby
• 36 hours in type, 9.4 at night- not too shabby
• Flew that route 35 times in the previous 15
  months, 17 times without a CFI and 5 were at
  night. Pretty good record, hey!
• In the past 100 days before the accident the
  pilot completed 50 of the IFR course.

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Questions

• In light of the notes, was the pilot too cocky?
• Was he acting irresponsible by not having an
  instructor on board? Being rich and famous he
  could afford anything.
• Could you see yourself in a parallel situation
  during your flying career?

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My Opinion

• I could and have seem myself in his situation and
  at the time.
• Unfortunately, the pilot had similar instruction
  to myself, the difference being I took my
  instruction in 1970.
• The same old stuff, no new stuff. GA must change
  and give pilots the tools to face new situations.

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Only the facts mame

• Forecast- 4-10 miles over the route
• Dark night- I guess that means a high overcast
• Route over land at 5500 feet, then crossing water
  34 miles west of Marthas Vineyard started
  descent at 400-800 fpm
• Leveled off at 2200, then climbed back to 2600.
  What was his intended level off altitude?

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What Happened Next?

• While still in the descent, the airplane entered
  a right turn. The rate of descent and airspeed
  increased eventually exceeding 4700 fpm.
• Examination of wreckage revealed no mechanical
  malfunction

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NTSB

• The pilots failure to maintain control of the
  airplane during a descent over water at night,
  which was a result of spatial disorientation.
  Factors in the accident were haze, and the dark
  night.

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What went wrong?

• Failure to get flight following? Would it have
  helped? Would pre-tuning 121.5 helped if he
  selected it and made a call?
• Altitude awareness or control? First 2200, then
  2600?
• Proper reaction to spatial disorientation? With
  50 if IFR training complete, what should he have
  known to do?

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Procedures that might have helpedhardware,softwa
re,humanware

• Flight Following?

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Do You Use?

• Altitude Awareness procedures, altitude alert
  system

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Hardware and software

• Set desired altitude target
• Alert system signal when 1000 feet to go
• Set MDA or pattern altitude in the alert system
• Set field elevation next

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Hardware

• USE of autopilot?

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What do you do when you dont know which end is
up?

• Believe your flight instruments
• Engage your autopilot
• What do you do when equilibrium is regained.

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Actions

• Divert to better weather
• Get assistance
• Land ASAP
• Critique flight
• Make a flight plan for the future

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Future Flying

• Examine and adopt applicable procedures developed
  through HF/ CRM studies
• Altitude awareness, automation, unusual attitude
  practice and needle ball practice more often
• CRM-flight following and use of radio for help
• Consider pinch hitter program for partner

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One more story

• Captain- Ladies and gentlemen, this is your
  captain. The wx is good and we should have a
  smooth and uneventful flight, now sit back and
  relax, OH, MY,GOD! Then silence.
• Ladies and Gentlemen, I am sorry if I scared you
  you earlier, the flight attendant accidentally
  spilled coffee in my lap, you should see the
  front of my pants!
• From the back a passenger in Coach yelled,
• Thats nothing, you see the back of mine

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FAA Industry Training Standards

• FITS Overview

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Outline

• FAA Industry Training Standards
• Problems with Current Training
• FITS Flight Training
• Scenario Based Training
• Single Pilot Resource Management
• Learner Centered Grading
• 5 Ps

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FITS Goals

• Increase GA safety
• Reduce number of accidents
• Improve pilot skills and decision making
• Increase efficiency and standardization of pilot
  training
• Reduce pilot training time
• Reduce cost of pilot training

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Problems with Current Training

• Train to pass test, rather than practical
  operations in a modernized NAS.
• Training maneuvers, rather than ADM /risk
  management.
• Insufficient emphasis on new flight technologies
  (GPS/MFD/AP).

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FITS Flight Training

• Increased emphasis on decision making
• ADM/RM/TM/AM/SA/CFIT Awareness
• Weather decision making
• Information management
• Emphasis on scenario based training train the
  way you fly and fly the way you train
• Integrated ab-initio and instrument rating

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Scenario Based TrainingSBT

• Training system that uses a highly structured
  script of real-world experiences to address
  flight training objectives in an operational
  environment.  
• New learning techniques emphasis
• Student role as active learners
• Emphasis on thinking and understanding
• Learning activities emphasize authentic, real
  world contexts for learning.
• The object of SBT is a change in the thought
  processes, habits, and behaviors of the students.

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Single Pilot Resource Management (SRM)

• The art and science of managing all the
  resources
• (both on-board the aircraft and from outside
  sources) available to a single-pilot (prior and
  during flight) to ensure that the successful
  outcome of the flight is never in doubt.
• SRM training helps the pilot maintain
  situational awareness by managing the automation
  and associated aircraft control and navigation
  tasks. This enables the pilot to accurately
  assess and manage risk and make accurate and
  timely decisions.

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Learner Centered Grading

• Maneuver Grades (Tasks)
• Explain at the completion of the scenario the
  PT will be able to describe the scenario activity
  and understand the underlying concepts,
  principles, and procedures that comprise the
  activity. Significant instructor effort will be
  required to successfully execute the maneuver
• Practice at the completion of the scenario
  the student will be able to plan and execute the
  scenario. Coaching, instruction, and/or
  assistance from the CFI will correct deviations
  and errors identified by the CFI
• Perform at the completion of the scenario, the
  PT will be able to perform the activity without
  assistance from the CFI. Errors and deviations
  will be identified and corrected by the PT in an
  expeditious manner. At no time will the
  successful completion of the activity be in doubt
• Not Observed Any event not accomplished or
  required

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Learner Centered Grading

• Single Pilot Resource Management (SRM) Grades
• Explain the student can verbally identify,
  describe, and understand the risks inherent in
  the flight scenario. The student will need to be
  prompted to identify risks and make decisions.
• Practice the student is able to identify,
  understand, and apply SRM principles to the
  actual flight situation. Coaching, instruction,
  and/or assistance from the CFI will quickly
  correct minor deviations and errors identified by
  the CFI. The student will be an active decision
  maker.
• Manage/Decide - the student can correctly gather
  the most important data available both within and
  outside the cockpit, identify possible courses of
  action, evaluate the risk inherent in each course
  of action, and make the appropriate decision.
  Instructor intervention is not required for the
  safe completion of the flight.
• Not Observed Any event not accomplished or
  required

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The 5 P Check

• The Plan
• The Plane
• The Pilot
• The Passengers
• The Programming

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Bobs Restaurant Slogan, Manteo North Carolina

• Welcome to Bobs
• Eat and then get the hell out