Maximizing Human Factors Training Effectiveness

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Maximizing Human Factors Training Effectiveness

• Steven C. Predmore, Ph.D.
• Vice President Chief Safety Officer
• JetBlue Airways

Presented at a joint conference of the Royal
Aeronautical Society Human Factors Committee and
the Rail Safety Standards Board May 21,
2009 London
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A bit about JetBlue

• Mission Bring Humanity Back to Air Travel
• Began operations in February 2000
• 11,500 Crewmembers
• 600 flights daily
• Main base of operations is JFK (NYC)
• Focus Cities JFK, BOS, LGB, FLL, MCO
• Cities served 53 cities in the Americas and
  Caribbean
• Fleet 41 Embraer E190s, 108 Airbus A320s
• Business Model
• Low Cost, Value-oriented airline
• Emphasis on Customer Service

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Where we jet
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Cockpit Resource Management

• Pilot-centric
• CRM concepts
• Psychological Factors
• Personality
• Attitudes
• The Right Stuff
• Social dynamics inside the cockpit
• Largely, a training solution
• Business Case Loss avoidance catastrophic
  accidents

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Crew Resource Management

• Crew dynamics beyond the cockpit
• Cabin crew
• Air Traffic Control
• Maintenance
• Dispatch
• Focus on flightcrew interactions and performance
• Still, heavy reliance on training solutions
• Business Case Loss Avoidance incidents,
  ground damages, injuries

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Threat Error Management

• Looks at the total operational and safety
  environment
• Resources
• Barriers to adverse outcomes
• Measures external threats
• Provides a model for structured observation and
  assessment -- LOSA
• Business Case Greater safety, efficiency,
  reliability through quality improvements

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Our Basic Threat Error Model
Defenses
Threats
Undesired State
Error
Accident, Incident, Violation
Prevent
Trap
Mitigate
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Defenses
Automation Management
Flows Checklists
Situational Awareness
External People
Hardware
Teamwork
Accident, Incident, Violation
Threats
SOPs
What If Planning
Communications Briefings
Flying Skills
Time Management
Other Pilot
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Some defenses are provided to you
Automation Management
Flows Checklists
Situational Awareness
External People
Hardware
Teamwork
Accident, Incident, Violation
Threats
SOPs
What If Planning
Communications Briefings
Flying Skills
Time Management
Other Pilot
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and some defenses you provide.
Automation Management
Flows Checklists
Situational Awareness
External People
Hardware
Teamwork
Accident, Incident, Violation
Threats
SOPs
What If Planning
Communications Briefings
Flying Skills
Time Management
Other Pilot
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Defenses are Enhanced By Training
Automation Management
Flows Checklists
Situational Awareness
External People
Hardware
Teamwork
Accident, Incident, Violation
Threats
SOPs
What If Planning
Communications Briefings
Flying Skills
Time Management
Other Pilot
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Defenses are Enhanced By Training
Flows Checklists
Accident, Incident, Violation
Threats
Flight Training - Flight Training Devices -
Simulators
SOPs
Flying Skills
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Defenses are Enhanced By Training
External People
Teamwork
Accident, Incident, Violation
Threats
CRM Training
Other Pilot
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Defenses are Enhanced By Training
Automation Management
Situational Awareness
Teamwork
TEM Training
Accident, Incident, Violation
Threats
What If Planning
Communications Briefings
Time Management
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TEM Toolkit Defenses
What If Planning
Time Management
Communications Briefings
Accident, Incident, Violation
Threats
Automation Management
Situational Awareness
Teamwork
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Communications Tools

• Think Out Loud
• Dont play I have a secret
• If you are thinking about doing something in the
  future, SPEAK UP!
• Ask Questions
• If you are wondering about something ASK!
• Questions help us maintain/regain our S.A. (more
  to follow)
• Be Specific
• Avoid Hint and Hope
• Do you think this is going to work? vs. I show
  you 2 dots high
• Whew, thatll be tight vs. Thatll put us on
  the ground with less than 4000

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TEM isnt just Safety training

• The TEM model translates easily into any quality
  domain
• Operational reliability
• Customer service
• Compliance
• All of these aspects of quality are
• subject to environmental threats
• adversely impacted by human error, the failure to
  capture errors, and ineffective mitigation
  strategies

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Briefings Tools

• Brief the Bottom Lines
• If were still in this holding pattern with 6000
  lbs, then well divert.
• Were going to delay the flight 25 min for
  connecting customers.
• Brief the Exceptions (Whats different?)
• Lets not forget weve got an inoperative thrust
  reverser and the runway might be slippery, so
  lets not float, and be ready for possible
  directional control problems.
• A tailjack should NOT be used for this procedure
  on the Embraer.
• Brief Contingency Plans
• If we have to go around, well turn left instead
  of right to avoid those storms.
• If the schools close, well need to contract
  daycare for Systems Operations personnel.

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Training Limitations

• Despite the unquestioned success of Human Factors
  training in flight safety, we have not seen the
  institutionalization of similar training in other
  operational domains. Why not?
• Absence of required recurrent training
  opportunities
• Cost effectiveness unclear
• Turnover/Attrition rates
• Lack of champions
• Threat Error Management lends itself to
  measurement and evaluation as a next step

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Line Operations Safety Audits (LOSA)

• Health check of Flight Operations
• Observation of routine operations by trained
  observers
• Data collected using a Threat Error Management
  framework
• Threats - factors the crew needed to address
  (weather, challenging ATC clearances, aircraft
  malfunctions, etc.)
• Errors mistakes or oversights in handling a
  threat
• Supplements other Safety Programs
• Identifies daily strengths and weaknesses of the
  operation without relying on an incident

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Methodology

• Conducted with assistance of The LOSA
  Collaborative (TLC)
• Internal and External Observers
• Extensive Observer training calibration
• Representative sample of flights chosen
• Data collected, analyzed and reported by TLC
• Profiles are built
• Threats
• Errors
• Undesired Aircraft States
• Countermeasures

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What did LOSA tell us about the Threats in our
Operation?

• Threat profile was comparatively normal in most
  respects
• 95 of flights
• 3.6 per flight
• Ground/Ramp
• Operational Pressures
• Challenging ATC environment

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Traditional Safety Programs

• Traditional Safety programs are like the game
  Whack a Mole
• Reactive
• Repetitive
• Inefficient
• Exhausting
• Too often, training has been the only/first
  hammer to whack with
• We need more tools, like LOSA, that are
  diagnostic and predictive so that we can maximize
  the effectiveness of our training programs

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Safety Management Systems

• Safety Policy
• Management commitment responsibility
• Safety accountabilities
• Key safety personnel
• Emergency Response planning
• Documentation
• Key Programs
• Just Culture initiatives
• Internal Evaluation
• Emergency Response

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Safety Management Systems

• Risk Management
• Hazard identification
• Risk assessment and mitigation
• Key Programs
• Safety Reporting
• ASAP
• Investigations
• Safety Review Boards

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Safety Management Systems

• Safety Assurance
• Safety performance monitoring and measurement
• Management of change
• Continuous improvement of safety programs
• Key Programs
• Aircraft Data Monitoring (FOQA)
• LOSA
• Line Check program

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Safety Management Systems

• Safety Promotion
• Training education
• Safety communications
• Rewards and recognition
• Key Programs
• CRM Training
• TEM Training
• Newsletters
• Safety Awards

Four Pillars of SMS
Safety Promotion
Safety Assurance
Safety Policy
Risk Management
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In conclusion

• Early HF training was easily justifiable
• Avoidance of catastrophic accidents
• Absence of soft skills in training curriculum
• New approaches to HF go well beyond training
• Training not cost effective in all areas
• TEM provides a good model for risk assessment and
  health monitoring
• Training effectiveness is maximized when it is
  part of a Safety Management System
• Focus on quality management principles
• Diagnostic, predictive, measurable