Maximizing Human Factors Training Effectiveness

1. 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

2. 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 E190’s, 108 Airbus A320’s • Business Model: • Low Cost, Value-oriented airline • Emphasis on Customer Service

3. Where we jet…

4. 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

5. 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

6. 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

7. Our Basic Threat & Error Model Defenses Threats Undesired State Error Accident, Incident, Violation Prevent Trap Mitigate

8. Defenses Automation Management Flows & Checklists Situational Awareness External People Hardware Teamwork Accident, Incident, Violation Threats SOP’s “What If” Planning Communications & Briefings Flying Skills Other Pilot Time Management

9. Some defenses are provided to you… Automation Management Flows & Checklists Situational Awareness External People Hardware Teamwork Accident, Incident, Violation Threats SOP’s “What If” Planning Communications & Briefings Flying Skills Other Pilot Time Management

10. … and some defenses you provide. Automation Management Flows & Checklists Situational Awareness External People Hardware Teamwork Accident, Incident, Violation Threats SOP’s “What If” Planning Communications & Briefings Flying Skills Other Pilot Time Management

11. Defenses are Enhanced By Training Automation Management Flows & Checklists Situational Awareness External People Hardware Teamwork Accident, Incident, Violation Threats SOP’s “What If” Planning Communications & Briefings Flying Skills Other Pilot Time Management

12. Defenses are Enhanced By Training Flows & Checklists Accident, Incident, Violation Threats Flight Training - Flight Training Devices - Simulators SOP’s Flying Skills

13. Defenses are Enhanced By Training External People Teamwork Accident, Incident, Violation Threats CRM Training Other Pilot

14. Defenses are Enhanced By Training Automation Management Situational Awareness Teamwork T&EM Training Accident, Incident, Violation Threats “What If” Planning Communications & Briefings Time Management

15. T&EM “Toolkit” Defenses “What If” Planning Time Management Communications & Briefings Accident, Incident, Violation Threats Automation Management Situational Awareness Teamwork

16. Communications Tools • Think Out Loud • Don’t 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, that’ll be tight” vs. “That’ll put us on the ground with less than 4000#”

17. TEM isn’t 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

18. Briefings Tools • Brief the Bottom Lines • “If we’re still in this holding pattern with 6000 lbs, then we’ll divert.” • “We’re going to delay the flight 25 min for connecting customers.” • Brief the Exceptions (What’s different?) • “Let’s not forget we’ve got an inoperative thrust reverser and the runway might be slippery, so let’s 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, we’ll turn left instead of right to avoid those storms.” • If the schools close, we’ll need to contract daycare for Systems Operations personnel.”

19. 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”

20. 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

21. 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

22. 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

23. 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

24. Four Pillars of SMS Safety Policy Safety Assurance Safety Promotion Risk Management 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

25. Four Pillars of SMS Safety Policy Safety Assurance Safety Promotion Risk Management Safety Management Systems • Risk Management: • Hazard identification • Risk assessment and mitigation • Key Programs: • Safety Reporting • ASAP • Investigations • Safety Review Boards

26. Four Pillars of SMS Safety Policy Safety Assurance Safety Promotion Risk Management 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

27. 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 Policy Safety Assurance Safety Promotion Risk Management

28. 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