Beyond Pilot Error: Aviation Safety and Training

1. Beyond Pilot Error: Aviation Safety and Training Kathy H Abbott, PhD, FRAeS Federal Aviation Administration Capt. John M. Cox, FRAeS Safety Operating Systems 27 April 2010

2. Pilots Are Unique People

3. Human error is the cause of accidents Human is the most unreliable component Improve safety by restricting human action Human error is the effect of deeper issues Human is necessary to create safety Improve safety by understanding (and leveraging) human performance Old View New View Human Error and Aviation Safety From Dekker 2002

4. Flexibility/ Adaptability Pilot Error Designer Error Risk Mitigation – Where? Design Engineer Pilot TCAS/ ACAS Envelope Protection Flight Director Cat III Autoland Circling Approaches

5. Overview • Flight Path Management and Flight Deck Automation – where can training be improved? • WHY do errors occur? • Looking beyond error at the “sharp end”

6. Flight Path Management and Flight Deck Automation – where can training be improved? • Performance-based Operations Aviation Rulemaking Committee (PARC) and Commercial Aviation Safety Team (CAST) PARC/CAST (preliminary results) • FAA International Rudder Survey • Recent accidents/incidents

7. Flight Deck Automation Working Group • Joint under the Performance-based Operations Aviation Rulemaking Committee (PARC) and Commercial Aviation Safety Team (CAST) • Current design, training and use of flight path management systems in transport airplanes in “121-like” operations • Preliminary results from: • 734 incidents from Aviation Safety Reporting System (ASRS) within scope • 46 major incidents and accident reports within scope • normal ops via Line Operations Safety Audit (LOSA)

9. X X X X X X X

10. Potential Areas for ImprovedPilot Training Manual handling Flight path management systems Unusual attitude avoidance, recognition and recovery Speed and energy management Use of rudder Managing malfunctions Managing distractions Crew coordination and communication

11. Turkish Airlines Flight TK 1951

12. Legal Regulatory Organization Equipment design, training, procedures Pilot Accident Adapted from Reason

13. Legal

14. Regulatory

15. Organization

16. Equipment Design Training Procedures

17. Pilot

18. Legal Regulatory Organization Equipment design, training, procedures Pilot Accident Data Collection? Investigations? Training?

19. Operators, Regulators, Manufacturers, Training Organizations… It is about training all the people

20. Old View New View Revised Human error is the cause of accidents Human is the most unreliable component Improve safety by restricting human action Human error is the effect of deeper issues Human is necessary to create safety Get away from blame and ask “why”? Improve safety by understanding (and leveraging) human and organizational performance Human Error and Aviation Safety

21. Thank You