The Other Things We Must Know!

1. The Other Things We Must Know! It’s All About The Safety……! Fred Harms

2. SAFETY IS #1!

3. Cost vs. Benefits Cost vs. Benefits Safety is a balancing act

4. Accidents are only the tip of the iceberg! ACCIDENTS INCIDENTS For every accident there are 600 errors and/or unreported occurrences ERRORS AND UNREPORTED OCCURRENCES

5. HUMAN FACTORS The term 'human error’ is used in recognition of the fact that most aviation accidents do involve human error at some point in the chain of events. these errors (or unsafe acts) tend to be just one link in a chain of events.

6. Human error is a symptom of trouble deeper inside the system. • Safety is NOT inherent in systems. People have to create safety. • Human error is connected to our tools, tasks and operating environment. Progress in safety comes from understanding and influencing these connections.

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8. Error, by any other name…. • Complacency — the failure to recognize the gravity of a situation or to adhere to standards of care or good practice. • Non-compliance — the failure to follow rules or procedures that would keep the job safe. • Loss of situation awareness — the failure to notice things that in hindsight turned out to be critical.

9. 3 Factors Leading to Human Error 1. Overload:is the imbalance between a person’s capacity (natural ability, training, state of mind), and added burdens resulting from environmental factors (noise), internal factors (stress) and situational factors (unclear instructions). 2. Inappropriate Response:If a person detects a hazardous condition but does nothing to correct it, or if a person removes or fails to use a safeguard, it is an inappropriate response. 3. Inappropriate Activities: A person who undertakes a task that he/she does not know how to do or misjudges the degree of risk in a given task and proceeds based on the misjudgment.

10. You have read the accident reports! VFR into IMC Equipment malfunction, but deferred “Let’s take a look and see” “If you can get it inside, it will fly” “Why check the weather, we’re going anyway!” “Although the weather was deteriorating, the pilot pressed on.”

11. Three factors in Intentional Non Compliance Motivation (Reward) High Probability of Success Absence of Peer Pressure or Reaction All three required, or intentional non-compliance does not occur.

12. Task Design – design tasks with working memory capacity in mind Equipment Design Minimize perceptual confusions – ease of discrimination Ex: airplane controls that feel like what they do (flaps, wheels) Make consequences of action visible – immediate feedback Ex: choice box in some software programs Lockouts – design to prevent wrong actions Ex: car that will not let us lock door if the key is still in Reminders – compensate for memory failures Ex: ATM reminds us to take our card Error Prevention / Mitigation

13. Training– provide opportunity for mistakes in training, to learn from them Ex: Scenario-based training/evaluations Assists and Rules – checklists to follow Ex: Pilot pre-flight checklist Error-tolerant systems – system allows for error correction or takes over when operator makes serious error Ex: Undo button in computer program Error Prevention / Mitigation

14. Failure? • Mistake?

15. The Focus of Flight Training Assumption – risk assessment skills will emerge as part of the training experience. Reality – we are trained within a specific operational environment and our experience is relatively selective. We have difficulty in accurately appraising our performance and anticipating hazards that we are likely to experience.

16. The Great Lie “When pilots fail to admit the risks, the odds are they won’t do a good job of managing those risks.” “The vast majority of fatal accidents are caused by a failure in risk management, yet flight training is focused almost exclusively on skill.” “The answer is that instructors must teach, and pilots must learn a practical, proactive procedure to anticipate and manage risks.” John King

17. A CLOSED MIND TO RISK LEADS TO ACCEPTANCE OF GREATER RISK.

18. Pilot Responsibility Knowledge/skill maintenance Motivation Know and comply with the rules and the standards Evaluate and support a Safety Culture

19. Prevention Strategies Recognize that… Procedures are there for a reason You (and your aircraft) have limitations The situation may be worse than you think Nothing is worth killing yourself for People want you home in one piece Self discipline is the key

20. School/FBO Responsibility Viability – staying in business Training/education Operating policies Support a Safety Culture Comply with the rules and uphold the standards

21. Flight Schools Face Unique Pressures Rote learning over cognitive – pass the check ride. Inner-generational blindness. Reactive day-to-day business management. Turn over rate high. Newness to the aviation System.

22. The Social Environment Human behavior is influenced by our social environment Social norms, mgmt practices, morale, training, incentives e.g. construction workers will not wear safety gear if no one else is

23. FAA Responsibility Create and enforce rules and standards Verify training and performance Properly select DPE’s, and assign responsibilities Impart a safety culture

24. ICAO Annex 6 “From 1 January, 2009, States shall require, as part of their safety programme, that an operator implement a safety management system acceptable to the State of the Operator…” The U.S. has filed a difference with ICAO Currently, there are no FAA authorized procedures to accept or approve Service Providers’ SMS’s

25. Development of a Safety Management System The story-line may seem familiar!

26. DPE Responsibility Knowledge Motivation Task design Support a Safety Culture Comply with the rules and uphold the standards

27. CFI Responsibility Teach and comply with the rules and standards Training/education Motivation Task design Impart a Safety Culture

28. When pilots leave the supervision of their instructor the accident rate goes up almost 50%!

29. Most pilots learn risk management by trial and error. Flight instructors can teach pilots specific risk management skills with scenarios that require the pilot to use those skills.

30. Considerations for Decision Making Pilots make improper decisions when they feel a pressure to go or continue. The safety culture or value system of any organization can influence how a pilot makes decisions. Completing a flight safely requires that every pilot develop a risk assessment and management plan, with personal minimums that are not compromised.

31. Final Thoughts! We can’t stop people from being human….so let’s build an error tolerant system of checks and balances. If something goes wrong, you can count on second guessers who have the benefit of hind sight….SO

32. Let’s Ask Ourselves These Questions…. Will my decisions and actions be: Prudent? Reasonable by company standards? Consistent with best practices? Bias to the conservative!

33. Other Things We Must Know Thank You For Attending The Central Region FAA Safety Team (FAASTeam) is dedicated to Quality Customer Service and we would value your feedback. Please provide your feedback at: www.faa.gov/about/office_org/headquarters_offices/avs/offices/afs/qms