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A good day, or a bad day at the office … Depending on your perspective

A good day, or a bad day at the office … Depending on your perspective. Human Factors in Aviation. Design Delegation Holders, 20 October 2005. Dr Dougal Watson Principal Medical Officer Civil Aviation Authority Lower Hutt New Zealand. A good day at the office!.

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A good day, or a bad day at the office … Depending on your perspective

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  1. A good day, or a bad day at the office … Depending on your perspective

  2. Human Factors in Aviation Design Delegation Holders, 20 October 2005 Dr Dougal WatsonPrincipal Medical OfficerCivil Aviation AuthorityLower Hutt New Zealand

  3. A good day at the office!

  4. Human Factors:What’s it mean? Human Factors in action: On the way to Auckland this morning.

  5. Human Factors:What’s it mean? What is Human Factorsand what is it not? Human Factors = Ergonomics

  6. Human Factors:Design engineering

  7. Human Factors:Definition 1 • Human Factors is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance. International Ergonomics Association (http://www.iea.cc)

  8. Human Factors:Definition 2 • "Human Factors is about people: it is about people in their working and living environments, and it is about their relationship with equipment, procedures, and the environment. Just as importantly, it is about their relationships with other people ... Its two objectives can be seen as safety and efficiency.'' ICAO Circular 227

  9. Not such a good day at the office!

  10. Human Factors:Definition 3 • Why do smart people do dangerous / dumb things?

  11. Human Factors:Involves humans. “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997.

  12. A bad day at the office!

  13. Human Factors:Why do smart people do dangerous / dumb things? • Excessive Workload • Physical and cognitive effort involved in task performance. • Lack of Situation Awareness • What’s going on? • What’s likely to happen next? • What will happen if I take a particular action? • Excessive Stress, Fatigue, Uncertainty, etc. • Impacts perceptual-motor performance, decision-making, etc. • Diminished Attention • Too much to attend to at once (overload) • Too little to attend to for too long (underload) • Poor Teamwork and Communication • Often due to poor layout of work space and/or poor layout of command and communication structure • Quality engineering can help avoid virtually all of these problems

  14. Human Factors:Avoiding Errors. • Plan, design, manufacture, and implement systems that: • Utilise human capabilities; • Cater to human limitations: • Redundancies; • Layered defences; • Fail-safe design etc etc etc • Train & equip humans to: • Utilise the system; • Recognise and minimise their limitations; • Learn from errors.

  15. Not a good day at the office!

  16. Human Factors:Domains within Human Factors • Physical • anatomical, anthropometric, physiological and biomechanical characteristics as they relate to physical activity • Cognitive • mental processes, such as perception, memory, reasoning, and motor response, as they affect interactions among humans and other elements of a system • Organisational • optimization of socio-technical systems, including their organizational structures, policies, and processes • Somewhat artificial delineation, in part reflecting the training background of the practitioners

  17. Human Factors:Who does Human Factors? • Multi-Disciplinary HF Specialists • Some: • Psychologists • Engineers • Doctors • Kinesiologists • Retrained Subject Matter Experts … Yes, it is possible to retrain engineers (pilots and doctors) • Scientists

  18. Another bad day at the office!

  19. Human Factors:What is not Human Factors? • “Just applied common sense” • Training people to accommodate poor design • Blaming the user • “Pilot error” • Designers projecting their skills onto users • If it’s easy for the designer it must be easy for the end user • Human Resources • The Navy

  20. Human Factors:Why isn’t everyone doing it? • “Voodoo Ergonomics” • Everyone is an Operator … “It’s just common sense!” • While nobody intentionally designs systems to interfere with human performance, they may resist the up-front expense associated with “doing it right.” • HF folk have advertised & documented their benefits poorly

  21. Human Factors:What about aviation? • Over the past 40 years, over 80% of accidents and incidents were related to the human element and were largely preventable through the proper application of Human Factors principles. • If the accident or incident rate is to be decreased, human factors must be better understood and the knowledge more broadly applied. http://www.cami.jccbi.gov/AAM-600/610/600Air-HFB.html

  22. A good day at the office!

  23. Human Factors:Some examples.

  24. Human Factors in Everyday Life:Medicine Let he who is without sin … • Six accidents involving massive radiation overdose to patients (1985 - 1987) • Therac-25 radiation treatment device • Controlled remotely • “Sloppy engineering” … “one of the most devastating computer related disasters to date” • “A combination of technical failures (software and possibly hardware) combined with human behaviour resulting in catastrophic radiation overdoses” • ‘Voluntary’ recall of equipment • Risk mitigation => hardware design, software design, or training?

  25. Human Factors in Everyday Life:Footpaths Things that get in your way. • People usually follow footpaths when they’re convenient. • Many people take the path of least resistance. • Take a hint from people's behaviour. • What does the savvy civil engineer or builder do?

  26. Human Factors in Everyday Life:Centre High-Mounted Stop Lights Human Factors innovation • NTSB estimates $910 million savings pa just in property damage. • Also many millions in medical costs saved. • $5 million spent in developmental research and regulatory programs. • What CFO wouldn’t see the attractiveness of over $1 billion annual return on a $5 million one-off investment?

  27. A great day at the office!

  28. Human Factors in Everyday Life:Mop Sink Things that don’t work the way you expect • Men’s washroom in restaurant. • No urinal. • Sign over the mop-sink. • The mop sink looks enough like a urinal for it to be used as one. • When simple things have signs, especially homemade signs, it is usually a signal that they aren't well-designed.

  29. MAIL BOX RENTALS 931 ROSELLE RD SCHAUMBURG 60193 708 893-5705 MAIL BOXES ETC 836 ARLINGTON HEIGHTS RD ELK GROVE VILLAGE 60007 708 956-1112 1749 W GOLF RD MOUNT PROSPECT 60056 708 640-7788 318 HAY DAY ROAD BUFFALO GROVE 60069 708 123-4567 830 W MAIN ST LAKE ZURICH 60047 708 459-7060 126 EAST WING HOFFMAN ESTATES 60195 708 310-4402 836 ARLINGTON HEIGHTS RD ELK GROVE VILLAGE 60007 708 956-1112 1749 W GOLF RD MOUNT PROSPECT 60056 708 640-7788 318 HAY DAY ROAD BUFFALO GROVE 60069 708 123-4567 830 W MAIN ST LAKE ZURICH 60047 708 459-7060 126 EAST WING HOFFMAN ESTATES 60195 708 310-4402 1749 W GOLF RD MOUNT PROSPECT 60056 708 640-7788 318 HAY DAY ROAD BUFFALO GROVE 60069 708 123-4567 830 W MAIN ST LAKE ZURICH 60047 708 459-7060 126 EAST WING HOFFMAN ESTATES 60195 708 310-4402 Mail Box Rentals 931 Roselle Rd SCHAUMBURG 60193 708 893-5705 Mail Boxes etc 836 Arlington Heights Rd ELK GROVE VILLAGE 60007 708 956-1112 1749 W Golf Rd MOUNT PROSPECT 60056 708 640-7788  318 Hay Day Road BUFFALO GROVE 60069 708 123-4567 830 W Main St LAKE ZURICH 60047 708 459-7060 126 East Wing HOFFMAN ESTATES 60195 708 310-4402 836 Arlington Heights Rd ELK GROVE VILLAGE 60007 708 956-1112 1749 W Golf Rd MOUNT PROSPECT 60056 708 640-7788 318 Hay Day Road BUFFALO GROVE 60069 708 123-4567 830 W Main St LAKE ZURICH 60047 708 459-7060 126 East Wing HOFFMAN ESTATES 60195 708 310-4402 1749 W Golf Rd MOUNT PROSPECT 60056 708 640-7788 318 Hay Day Road BUFFALO GROVE 60069 708 123-4567 830 W Main St LAKE ZURICH 60047 708 459-7060 126 East Wing HOFFMAN ESTATES 60195 708 310-4402 Human Factors in Everyday Life:Call Centre CRT Display Human Factors innovation • Mixed-case text, plus highlighting of selected listing. • Saved 600ms in average call operating time. • Translated to $2.94 million per year. • Small investment, small obvious improvement, good return at the bottom-line.

  30. Human Factors in Everyday Life:Car Seat Adjustment Controls with unexpected function. • Want to slide the seat back? Reach down and pull the lever. • Lever quickly detaches the whole seat. • No-one likely to want to detach a seat while sitting in it. Move the control to somewhere it can’t be reached while sitting.

  31. Human Factors in (not exactly) everyday life:Shuttle Cockpit

  32. Shuttle APU Display(off-nominal conditions) • Benefits: • The sub-systems are separated (e.g., landing gear, brakes, drag chute). • • Important information (landing gear) is displayed at the top. • • Color-coding separates different components such as labels and data. • • Off-nominal elements are color-coded. This display is a work-in-progress which needs to undergo testing and evaluation. Even after revisions, it might not be implemented on the shuttle because of budget constraints or other factors.

  33. Human Factors in (not exactly) everyday life:Challenges on ISS for Emergency Escape • Problem – Disorientation & lack of ISS architectural awareness • Disorientation reported on ISS in Node 1, as well as Mir • On-orbit is the first experience with the entire lay-out of ISS • Visiting Crews will not have time to learn the ISS layout • Disorientation can increase translation time and impact efficiency & safety

  34. Solution: Phosphorescent Emergency Egress Path Placards • Icons & Arrows • Indicate distinct multiple egress paths to the specific vehicles • Icons & text provide redundant cueing • Adaptable to location within ISS • Russian Text for the Soyuz when used in the FGB and SM • Phosphorescent • Self-illuminated relative to surroundings • Facilitate identification in reduced visibility conditions • Change out every 2 years

  35. Human Factors in Aviation:C150 ‘Human Factors’ not always right. • Human Factors expert analysis. • Inconsistent design wrt throttle and carbie heat controls.

  36. How Cessna 150s are made

  37. Human Factors in Aviation:Light aircraft emergency fuel management • Checking or changing fuel supply in an emergency?

  38. Human Factors in Aviation:S35 & V35 Bonanzas Change fuel tank in an emergency. • Fuel control handle under the front of the pilot seat, on the left beside cabin wall • Seat often needs to be slid back to access control • Especially for a short-ass pilot like me • Sliding seat back can make full control input impossible. Otherwise a great aeroplane.

  39. Not such a good day at the office! Nothing new under the sun

  40. Human Factors in Aviation:Cali Air Disaster AA965 B757 21DEC95 • Classic case of “human error” complicated by sleep deprivation. • Programmed autopilot to lock on to “Romeo” beacon instead of “Rozo.” • Caused slow turn into a mountain. • 150 killed. • Cockpit voice recorder captured crew complaints of excessive fatigue, yawning, etc. • 1997 Pulitzer Prize

  41. Human Factors in Aviation:C-141 Starlifter Human Factors in design • 40 years ago. Multi-role aircraft concept employing roll-on / roll-off alternative mission kits. • Kits heavy and complex and required lots of time and effort to install. • HF analysis of mission profiles and equipment needs lead to complete restructuring of equipment deployment. • $500k investment lead to $5M initial savings. • What would your CFO think?

  42. It’s all a matter of perspective Speedbird 245: Caution, FOD hazard ahead! Speedbird 245: You’re number two behind a Cessna. Beware wake turbulence!

  43. Human Factors in Aviation:British Midlands Air Disaster (Kegworth) B737-400 08JAN89 • Fan blade in left engine detached during climb => compressor stall. • Crew throttled back right engine & shuddering stopped. Right engine shutdown. • Almost normal emergency approach for some time then increased vibration again from left engine and then abrupt loss of power. • Couldn’t restart right engine. • Aircraft struck a field adjacent to M1 motorway. 47 dead, 74 seriously injured. • A problem of perceptual sets where pax and cabin crew had noted smoke from the left engine but the information was inadequately communicated to the flight deck.

  44. There must be a human factors message in this … somewhere

  45. Please!!!Human Factors, aviation, and you. • - A plea to the engineers involved in aviation • Good human factors in the design, development, manufacture, and maintenance of aircraft and aviation systems will reduce safety failures … big time! • Good human factors will also financially benefit your employer • Good ergonomics is good economics (google-it!)

  46. Human Factors Resources • Internet • Books, Reports, & Magazines • Massey, Auckland, & Otago Universities • RNZAF (Not the Navy though) • Colleagues, Clubs, & Societies • Private Companies • Formal training of our people

  47. Whenever we talk about a pilot who has been killed in a flying accident, we should all keep one thing in mind. They made a judgment. They believed in it so strongly that they knowingly bet their life on it. That their judgment was faulty is a tragedy,… Every engineer, instructor, supervisor, doctor, and contemporary who ever spoke to them had the opportunity to influence their judgment, so a little bit of all of us goes with every pilot we lose.

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