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The Other Things We Must Know!. It’s All About The Safety……!. Fred Harms. SAFETY IS #1!. Cost vs. Benefits. Cost vs. Benefits. Safety is a balancing act. Accidents are only the tip of the iceberg!. ACCIDENTS. INCIDENTS.

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the other things we must know

The Other Things We Must Know!

It’s All About The Safety……!

Fred Harms

slide3

Cost vs. Benefits

Cost vs. Benefits

Safety is a balancing act

slide4

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

human factors
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.

human error is a symptom of trouble deeper inside the system
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.

error by any other name
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.

3 factors leading to human error
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.

you have read the accident reports
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.”

three factors in intentional non compliance
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.

error prevention mitigation
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
error prevention mitigation1
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
slide14

Failure?

  • Mistake?
the focus of flight training
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.

the great lie
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

pilot responsibility
Pilot Responsibility

Knowledge/skill maintenance

Motivation

Know and comply with the rules and the standards

Evaluate and support a Safety Culture

prevention strategies
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

school fbo responsibility
School/FBO Responsibility

Viability – staying in business

Training/education

Operating policies

Support a Safety Culture

Comply with the rules and uphold the standards

flight schools face unique pressures
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.

the social environment
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

faa responsibility
FAA Responsibility

Create and enforce rules and standards

Verify training and performance

Properly select DPE’s, and assign responsibilities

Impart a safety culture

icao annex 6
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

slide25

Development of a Safety Management System

The story-line may seem familiar!

dpe responsibility
DPE Responsibility

Knowledge

Motivation

Task design

Support a Safety Culture

Comply with the rules and uphold the standards

cfi responsibility
CFI Responsibility

Teach and comply with the rules and standards

Training/education

Motivation

Task design

Impart a Safety Culture

slide29

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.

considerations for decision making
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.

final thoughts
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

let s ask ourselves these questions
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!

other things we must know
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