Human Factors for Part 135 Air Operators. Beyond Filling the Square. Human Factors and/or CRM Training?. Who? Where? When? . Human Factors. A multidisciplinary field devoted to optimizing human performance and reducing human eror. (OOOPS!). Human Factors.
Human Factors forPart 135 Air Operators Beyond Filling the Square
Human Factors and/orCRM Training? • Who? • Where? • When?
Human Factors A multidisciplinary field devoted to optimizing human performance and reducing human eror. (OOOPS!)
Human Factors The study of human – machine interaction in context
Ergonomics Designing the machine and task to fit the human (or not)
Quick CRM History • 1940's - Military • 1970's - Accident Studies/ ASRS • 1980's - Pilot Judgment Training • 1980's - Cockpit Resource Management • 1990's - Crew Resource Management • 2000's – Threat & Error Management • 2010's - Same Stuff, Different Day
Lack of Accidents ≠ Safety! 1 in 600
Safety The freedom from danger, risk, or injury.
It Won’t Happen To Me! WHEN ANYONE ASKS ME HOW I CAN BEST DESCRIBE MY EXPERIENCE IN NEARLY FORTY YEARS AT SEA, I MERELY SAY, UNEVENTFUL. OF COURSE THERE HAVE BEEN WINTER GALES, AND STORMS AND FOG AND THE LIKE, BUT IN ALL MY EXPERIENCE I HAVE NEVER BEEN IN AN ACCIDENT OF ANY SORT WORTH SPEAKING ABOUT. I HAVE SEEN BUT ONE VESSEL IN DISTRESS IN ALL MY YEARS AT SEA....I NEVER SAW A SHIPWRECK AND HAVE NEVER BEEN SHIPWRECKED, NOR WAS I EVER IN ANY PREDICAMENT THAT THREATENED TO END IN DISASTER OF ANY SORT.
It Won’t Happen To Me! • ON 14 APRIL 1912 RMS TITANIC SANK WITH THE LOSS OF 1500 LIVES - ONE OF WHICH WAS IT’S CAPTAIN....... E.J. SMITH
CRM Requirement for Part 135 http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=4af131373951c80175d09d635e196163&rgn=div8&view=text&node=14:126.96.36.199.188.8.131.52&idno=14
CRM § 135.330 Crew resource management training. (a) Each certificate holder must have an approved crew resource management training program that includes initial and recurrent training. The training program must include at least the following:
CRM • Authority of the pilot in command; (2) Communication processes, decisions, and coordination, to include communication with Air Traffic Control, personnel performing flight locating and other operational functions, and passengers; (3) Building and maintenance of a flight team;
CRM (4) Workload and time management; (5) Situational awareness; (6) Effects of fatigue on performance, avoidance strategies and countermeasures; (7) Effects of stress and stress reduction strategies; and (8) Aeronautical decision-making and judgment training tailored to the operator's flight operations and aviation environment.
CRM (b) After March 22, 2013, no certificate holder may use a person as a flightcrew member or flight attendant unless that person has completed approved crew resource management initial training with that certificate holder.
The “Roach Theory” of Errors Errors are like roaches... For every one you see...
“Threat and Error Management”(Dr. Robert Helmriech - U. of Texas) • Studied crews (watched them) • Looked at “threats” and “errors” • Categorized types of threats and errors • Analyzed events to learn from them
External Threats • Expected Threats • Forecast weather, terrain, fuel • Unexpected Threats • Mechanical problems, traffic, weather • Latent Systemic Threats • Accident waiting to happen • We've always done it this way
What is “Human Error?” • Action or inaction that leads to a deviation from yours or someone else’s intentions or expectations.
Errors Are Like Roaches • There are different species and sizes • Slips - meant to do the right thing but took incorrect action • Lapses - omitted an item • Mistakes - intention was incorrect • Intentional Non-Compliance - intentionally deviated from SOP or accepted procedure
Error Enhancers • Fatigue/excessive stress • Lack of oxygen/water/food • Distractions/interruptions • “First learned, best learned” • Insufficient situation awareness • Workload -too low or high
Human ErrorsLeading To “Events”... How many errors need to occur before we have an "event"?
What is an “Event?” • The breaching, absence or bypassing of some or all of the aviation system’s various defenses and safeguards.
Human Responses to Errors • Trap - error is detected and managed before it becomes consequential • Exacerbate - error is detected but the individuals’ action or inaction becomes consequential • Fail to Respond - lack of a response to an error (undetected or ignored) that can either end up being inconsequential or consequential
Error Management(aka) Roach Control • Detection and recovery • Understand and be vigilant for potential “error enhancers” • Prevent as many as possible Oh Noooo...
Your Company Culture • The set of shared attitudes, values, goals, and practices that characterizes an institution or organization • The set of values, conventions, or social practices associated with a particular field, activity, or societal characteristic
Human Factors for Air Operators Make Safety Your Culture