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Human Factors in Aviation

Human Factors in Aviation. P S Ganapathy Consultant (Flight Ops.) Jet Airways (India) Ltd. Human Factors in Aviation. Background and Justification Importance of Safety Civil Aviation Safety Record Causes of Accidents What is Human Factor? Benefits of Human Factor Training.

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Human Factors in Aviation

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  1. Human Factors in Aviation P S Ganapathy Consultant (Flight Ops.) Jet Airways (India) Ltd.

  2. Human Factors in Aviation Background and Justification Importance of Safety Civil Aviation Safety Record Causes of Accidents What is Human Factor? Benefits of Human Factor Training

  3. AVIATION SAFETY RECORD Quite impressive World wide accident rate of commercial large jet transport aircraft of the last three decades show a dramatic fall to 1.5 from 27per million departures 616 million passengers travel on US carriers in 1988 with no fatalities 1987-1996 (a decade) 600 Airlines had no accidents at all

  4. HULL LOSS--World Wide Jet FleetAccidents by Primary Cause (%) Causes 1988-971990-99 Human70.567.5 Airplane10.0 11.0 Weather5.0 7.5 Maintenance6.0 6.0 Airport/ATC3.0 4.0 Misc 5.5 4.0 Total 100.0 100.0

  5. HULL LOSS and /or Fatal Accidents(By phase of Flight) (%) Phase1988-97 1990-99 Taxi 8 8 Take off 1614 Climb 1213 Cruise 9 6 Descent 2 5 Approach 1713 Landing3641 5% flight time accounts for 60% of the accidents

  6. MAJOR AREAS OF ACCIDENTS Type 1990-971989-99 % Change Push back3846 +21 Hit by vehicle20 29 +45 CFIT 4736 -23 Landing 126157 +25 RTO2014 -30

  7. WHAT ARE THE LESSONS LEARNED? Ø Human Factor emphasis is paying Dividend at a slow pace ØGreater awareness has contributed to the reduction in CFIT Ø Technology continues to play a major role in accident prevention Ø Safety is a cost effective tool

  8. NEED FOR SAFETY ENHANCEMENT • Human error continues to dominate as the cause of aviation accidents (65 to 70 %) • Since 1970 the accident rate is relatively constant • As the number of flight departures increase, we can anticipate an increase in the absolute number of accidents. • Society does not understand the accident rates and is only concerned with the number of accidents irrespective of any decline in the global rates

  9. Accident investigation reports àThe crew reacted prematurely and in a way deviated from the laid down procedure àSeries of distractions and aggravations in the cockpit à The failure of the pilots to monitor flight instruments à Flight crews’ failure to use check list à Lack of team work amongst crew members

  10. Human factors & Flight safety How can we prevent accidents? Examination of Industry’s accident investigation reports clearly establishes that differentmanagement of available resourcescould have prevented the accidents in majority of the cases

  11. What are the available resources? Q Aircraft systems Q Procedure Q Manuals and check lists Q Cockpit crew Q Flight Despatchers Q Cabin crew Q Maintenance personnel Q ATC

  12. What is Management? It is the coordinated use of the available resources to reach a goal Q Set the goal Q Evaluate risk Q Set the priorities Q Allocate resources Q Evaluate results

  13. Development of Aviation Safety 1960 - 1980 Lonesome Heroes (Pilot Error) 1980- 1990 Crew Resource Management (Synergy) 1990-1999 Systemic Year (Organisation Dimension) WHAT IS IN STORE FROM 2000 ONWARDS?

  14. What is CRM? QThe effective utilization of all available resources to achieve safe and efficient operation of a flight QFocus of CRM training is on the functioning of the crew as an intact team, not simply as a collection of technically competent individuals QCRM aims at improving crew performance

  15. Human Factors HF is the Social Movement of learning the limit of human abilityand movement andperformance, to analyse and apply the knowledge gained to the daily operations to in prevent Human Failure which is themajor source of accidents Aviation

  16. What is Human Factor ? • Concerns with Optimizing the Relationship between People and their Activities by Systematic Application of Human Sciences Integrated with System Engineering. • It is aboutPEOPLE ; It is aboutPEOPLE intheir Working Environment and it is about their Relationshipwith Machines and Procedures.

  17. PROGRESS ON THE HUMAN FACTORS FRONT ICAO Since 1990, holding regular global flight safety and human factors symposium to bring in awareness. Incorporation of the requirement of human factors / CRM training and in accident / incident investigation in applicable annexes Regulatory authorities Inclusion of human factors training as mandatory in the training curriculum

  18. PROGRESS ON THE HUMAN FACTORS FRONT Airlines Imparting CRM Training to Operation personnel emphasizing the significance of human factors for enhanced performance Aircraft manufacturers Human limitations are taken into consideration in the design of the system / layout

  19. What is Human Factor Training ? • Not a substitute for Technical Training • Training directed to bring in CHANGE in Mindset Attitude Culture of Individual for enhancement of Safety and Efficiency

  20. Focus of Human Factors Training • Aviation Physiology • Aviation Psychology • Relationship- SHEL Model

  21. Human Factors Training Develops the INDIVIDUAL for Decision Making Effective Communication Leadership Interpersonal Skills Good Resource Management Handling of Stress Teamwork

  22. SHEL MODEL LIVEWARE {Human}is Centre Piece Live ware -Software Live ware - Hardware Live ware - Environment Live ware - Live ware

  23. SHEL MODEL • Live ware – Hardware Interface • Relationship between Human & Machine Work station Configuration Display and Control Design Seats

  24. SHEL MODEL • Live ware – Software Interface • Relationship between Individual and Supporting Systems . Regulations Manuals Check Lists Standard Operating Procedures

  25. SHEL MODEL • Live ware – Environment Interface • Relationship between Individual and the Internal & External Environment • Work area Temperature / Light / Noise / • Physical Environment Outside the Work area. Weather, Terrain, Infrastructure, etc.

  26. SHEL MODEL • Live ware – Live ware Interface • Relationship of individual with others in the Work area • Cockpit crew,Maintenance & cabin crew • Flight Dispatcher, Ground Support • Regulators • Management

  27. FLIGHT CREW AREAS OF WEAKNESS 30% ACTIVE FAILURE Non adherence to SOP Law violations / Lack of Vigilance Lack of Resource Management 20% PASSIVE FAILURE Misunderstanding, Distraction Complacency, Forgetfulness 45% PROFICIENCY FAILURE Inappropriate handling of A/C Misjudgment, Lack of Training 5% MISCELLANEOUS

  28. MAINTENANCE CREW WEAK AREAS • 56% OMISSIONS • 30% INCORRECT INSTALLATION • 8% INCORRECT PART • 6% MISCELLANEOUS

  29. THOUGHT PATTERNS HAZARDOUS ÜReplaceÜ ANTIDOTE ATTITUDE With • ANTI AUTHORITY: • “Don’t tell me.” “Follow the rules. They are usually right.” • IMPULSIVITY: “Do something- quickly.” “Not so fast. Think first.” • INVULNERABILITY: “It won’t happen to me.” “It could happen to me.” • MACHO: “I can do it.” “Taking chances is foolish.” • RESIGNATION: “What’s the use?” “I’m not helpless. I can make a difference.”

  30. WHAT ARE THE NEW TOOLS TO PREVENT ACCIDENTS? • Traditional reactive approach has to be replacedby proactive approachto reduce human error. • Encourage confidentialnon-punitive reporting system • Identify and eliminate adverse trends with theeffective use of DFDRto stop accidents before they happen • AUDIT OF THE SAFETY MATRIX

  31. WHAT CAUSES ACTIVE FAILURES? N E G L I G E N C E 14 + 5 + 7+ 12 + 9 + 7 + 5 + 14 + 3 + 5=81 + + E G O 5 + 7+ 15=27 + + I N C A P A C I T Y 9 + 14 + 3 + 1 + 16 + 1 + 3 + 9 + 20 + 25=101 =209 leads to H U M A N E R R O R 8+21+13+1+14+ 5+18+18+15+!8=131 AC C I D E N T S + 1+3+3+9+4+5+14+20+19=78 = 209

  32. WHAT IS THE SOLUTION? • INDIVIDUAL ATTITUDINAL CHANGE TO DO THINGS IN THE CORRECT MANNER AT THE FIRST INSTANT AS LAID DOWN IN THE MANUAL • SENSE OF PRIDE • TRUE MOTIVATION AND COMMITMENT

  33. REACTIVE APPROACHtoPROACTIVE APPROACH • Flight Operation Quality Assurance • Voluntary Incident Reporting System • Regular Safety Audit • Creating Safety Data Base and Trend Analysis

  34. NON-PUNITIVE INCIDENT REPORTING SYSTEMS • ( Air Safety Reports • ( Confidential Reports • ( Surveys

  35. STATISTICS (PER MILLION DEPARTURES) CountryAccident Rate Australia 0.2 USA & Canada 0.5 Europe 0.9 Middle East 2.3 Far East 2.6 South East 3.0 South America 5.7 Africa 13.0 THIS SHOWS“CULTURE”HAS AN INFLUENCE ON AVIATION SAFETY

  36. CULTURAL INFLUENCES ON AVIATI0N SAFETY • Attitude towards errors • Willingness to admit mistakes • Reporting if things are wrong • Keeping head down and not saying anything • Independent thinking and questioning

  37. Error, Performance and Safety Q Errors cause aircraft accidents Q Distinguish between errors and violation Error: Results when action deviates from intention; it is not intentional Violation: Results due intentional deviation from regulation or SOP; Initially intentional but can become routine

  38. Consequences of errors Consequences of an error may be very different. Therefore we must clearly differentiate between an error and its consequences Best example: Difference between an error made in the simulator and the exact same error made in the air. Errors can be detected in a tolerant system and corrected; behaviour is re-adopted.

  39. Call the colours Redblueyellowgreenblueyellowgreen red yellow greenredbluegreenred blue yellow redblue yellowred yellowgreenblueyellowbluegreenredyellowblue

  40. Error chain reaction With time,errors àproduce more and more negative effects à create conditions for new errors à contribute to accidents. Surrounding environment can turn a simple error into disaster.

  41. Error Management Prevention è Do not exceed your skills è Set your priorities, manage your time and workload è Learn from your errors; keep to the facts; do not listen to your ego. è Work as a team è Use checklists, callouts, cross checks è Adherence to SOP

  42. Update of situational awareness èAnticipate the future è Refer to past experience è Attend to one subject at a time

  43. Effective Communication Needs INQUIRY ADVOCACY LISTENING CONFLICT RESOLUTION CRITIQUE

  44. What is Inquiry ? • Information Seeking – Most Important • Visual Scan • Seeking Clarification from members • Overcoming the SensitiveEGO

  45. What is Advocacy ? • ABILITY TO STATE WHAT YOU KNOW OR BELIEVEIN A FORTHRIGHT POSITION • HOLDING TO YOUR VIEW POINT UNTIL IT IS PROVED BY FACTS, NOT BY AUTHORITY THAT IT IS WRONG

  46. What is Listening? • Active Listening is key to communication • Requires active ATTENTION • ListenMOREand SpeakLESS

  47. CONFLICT • Advocating own position • Becomes destructive if the argument is overwhois RIGHT rather thanwhatis RIGHT • Arguments have a serious effect on the quality of the decision • Not necessarily bad as long as they pertain to safety and efficiency

  48. How to resolve Conflict? Have a policy of coordination that is known and acceptable to every one When disagreement arises, keep the discussion only on the issues needing resolution Bring all issues of disagreement Acknowledge and express all feelings that are deep enough to cloud your thinking

  49. Conflict Resolution • Key to the highest level of problem solving • Leads to deeper thinking, creative to new ideas • Promotes mutual respect • Provides an opportunity to seek better solutions

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