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Managing human factors at Qantas:Investing in a new approach for the
""
future
B,\'Captain Jan L/lcas and Dr Graham Edkins
Following on from Captain Andrew Poulsen's article
reflecting on past and present human factors challenges
faced by Qantas, this article will outline a blueprint for
meeting these challenges. Specifically, the implementation
of a new corporate behaviour based training and
assessment program; and the need to better integrate
human factors principles into existing business and safety
systems.
According to the International CivilAviation Organisation (ICAO). themanagement of human error within theaviation industry is one of thegreatest challenges facing airlinemanagers in the new millennium(ICAO. 1993). Human error representsa real threat to airline safety andefficiency and in building a motivatedworkforce that understand the
challenges of today's and tomorrow'sbusiness environment.
The need to change
Australian aviation. Qantas included.remains the safest operatingenvironment on the world stage.While these safety achievements are
something to be proud of, there isfurther room for improvement. A lackof serious safety incidents has thepotential to reinforce a culture thatQantas is immune to airline accidents.lt is difficult to introduce continuous
improvement strategies wheneverything appears to be working.Human factors represents oneimportant area where further safetygains can be achieved.
Recent international developments inEurope and the United States on CRMskill assessment has led Qantas toreconsider its approach to humanfactors training. As a result of thework conducted by the Joint Aviation
Authority (JAA) on NOTECHS (Nontechnical skill evaluation in JAR-FCL)(van Avermaete, 1998) and research byBob Helmreich (Helmreich. 2000) onthe Line Orientated Safety Audit(LOSA); individual and attitude basedtraining and evaluation has beenreplaced by team orientatedbehavioural assessment. This has
been the motivation behind a QantasFlight Training development programcalled Advanced Proficiency Training(APT) which was initiated in early]999.
There is now a general acceptancethat expert performance of tasksinvolves both technical and non-
_ Corporate structure for human factors development---CD~ ••••~ ••
A Blueprint for Change
The question facing many airlinemanagers is not if but rather how tointegrate human factors principleswith current resource managementprograms. This section details howQantas proposes to achieve the abovementioned goals.
A Corporate Approach to HumanFactors
l
1
J
BUSINESSMANAGER
In recognition of the potential impactof human factors on Qantas businessobjectives, a Human Factors SteeringCommittee was formed in April 1998 toguide the extension of a newgeneration corporate human factorsprogram well beyond the cockpit toinclude error management acrossvarious operational divisions. Thestructure of this group is outlinedbelow.
identified can be used as learningtools by various operational areas.
Goal 4. Enhance operational andbusiness outcomes through humanfactors initiatives.
While financial imperatives should notbe the sole reason for embarking onhuman factors initiatives, we need to
get smarter at identifying what hasbeen the return on investment.
PROJECTPAlRONGeorge Bsey
GGMHR
HFS'IEERING GROUP
Senior Manage rs fmm:Flight 011" (Chair)
Cabin Senices
Engineering & lYbintOpemtions Resources
AirportsCa teringFreigh t
LFAD PROJECTMANAG ERDrGmham EdkinsMSE& HF
The focus of most airlines has been tocollect and trend data on human
performance problems from reactive,event based information, such as
reported safety incidents andaccidents. Given the unique humancapability to detect and recover fromerror, there is a lot of information that
we are not collecting because anincident may never have occurred.
Goal 3. Integrate hlllnanfactors
principles into existing business andsafety systems.
Human factors must not be isolated
from core business and safetyobjectives. There is a need toestablish a more systematic method ofensuring that the operational risks
the company is headed in regard tohuman factors.
Goal I. Identify the key competenciesof operational experts.
We need to identify and clearly definewhat behavioural competencies arerepresentative of safe and efficientperformance within stafffrom keyoperational areas of the company.
Goal 2. Develop a betterunderstanding of human performanceissues.
technical skills. Technical skills are
typically the procedural and factualknowledge required to complete atask, such as the highly practicedmanipulation skills of flight crew. Incontrast, non-technical skills mayinvolve reasoning, judgement andcommunication skills. While Qantashas been good at defining and trainingoperational staff in technical skills, itis the non-technical or behavioural
skills which need to be more clearlyspeci fied.
Apart from internationaldevelopments, there have also beensome local regulatory changes, whichare indicative of the increasingimportance of human factors forpassenger carrying operators. Forexample, the Australian Civil AviationSafety Authority (CAS A) has releaseda discussion paper, Civil AviationSafety Regulation (CASR) Part l21A,which proposes mandating CrewResource Management (CRM)/HumanFactors training for flight crew basedon nine modules. These nine modules
specify the basic training curriculumrequired during initial, recurrent,command and aircraft type conversionstages and follow that recommendedby the JAA.
CASR Part 121A also proposes thatflight crew should be regularlyassessed on their CRM competenciesduring line flying, consistent with thatrecommended by the European Unioncountries. This means that the formalevaluation of CRM behaviour will
become the norm for flight crew.However, it is the intention of Qantasto go much further than flight crewand make behavioural assessment a
regular practice for all its operationalstaff.
Organisational Goals Driving Change
The challenge for Qantas is to providehuman factors training that is not onlymeaningful for operational staff but
also useful for improving core safetyand business objectives. The
following goals outline the direction
12 Flight
Overall strategy
The role of the Human Factors
Steering Committee is to:
The project will identify and define the
non-technical or expected behaviours
required for safe performance within
senior operational staff across eachDivision. An assessment system will
then be developed to regularly assess
and reinforce these expected
providing management with a
structured process to assessspecific expected behavioursbased on core safety and businessobjectives.
Expected behaviours are actions thatare required to be demonstrated byoperational staff to achieve a safe andeffective operational outcome.
Behaviour based observation systems
will be tailored to the requirements of
each Division. For example, flight crew
will be assessed on expected
behaviours during route checks and
Line Orientated Flight Training (LOFT)
cyclic sessions using the Flight CrewObservation Record Form (FT 11)
currently under trial. (Shown on page15).
Stage 4. implementation of the
behaviour based observation system.
I Klein. G.A .. Calderll'ood. R. &MacGreg01: D. (/989). Crith'al decision
met/lOd for elicting knowledge. / EEETransactions on Systems. Man and
Cyhernetics, /9: 462-472.
Behaviour based observation systems
wi 11be developed so that managementcan assess that staff are
demonstrating the expected
behaviours trained in Stage 2. Qantas
has for many years assessed many of
its operational staff, such as cabin
crew and airports personnel, oncustomer service skills. Assessment of
behavioural skills underpinning safe
performance is seen as a natural
extension of our existing staff
appraisal systems.
External human factors consultancy
expertise will be sourced to develophuman factors training material based
on the expected behaviours identified
from Stage I. New hire operational
staff will be instructed in the expected
behaviours relating to their
operational area. In addition, current
operational staff wi 1Irecei ve training
and information on the expected
behaviours through new or existing
training courses.
Stage 3. Development and trial of
behaviour based observation system.
Stage 2. Development (~f human
factors training material to support
expected behaviours.
Regional airline staff.
Flight Crew;
Qantas catering personnel; and
Engineering & Maintenance staff;
Airports staff;
Freight staff;
Operations resources staff;
Cabin Crew;
•
Expected behaviours are developed
through a process called cognitive
task analysis, based on the Critical
Decision Methodl. This processinvolves interviewing a representative
sample (10%) of experienced staff (eg,
Captains, CS Ms, Senior LAMEs etc)
in each operational area to identify the
key behaviours (non-technical skills)that best determine effective and safe
job performance.
This process has already beencompleted within Flight Operations as
a result of the Advanced Proficiency
Training (APT) project. Approximatelysix categories of expected behaviours
have been developed for Flight Crew
relating to CRM/Human Factors
issues. The expected behaviours for
flight crew are shown on page 14.
behaviours, while providing trendinformation on those behaviours
posing a high potential risk to safety
and behaviours that represent highly
effective performance.
Staff affected by this program include:
The successful development and
implementation of this project will
involve five stages.
Stage i. Development of non
technical expected behaviours
Other operational divisions
progressively over the next two years
will adopt the same process todevelop their own expectedbehaviours.
providing staff with enhanced
skills to avoid, trap and mitigatehuman error; and
•
•
Development and assessment of
expected behaviours
To provide the foundation forcorporate human factors excellence, abehavioural training and assessmentproject across various operationaldivisions is proposed. This projectwill be managed by Or Graham Edkins,Manager Safety Education and HumanFactors and include Regional Airline,Union and CAS A involvement to helpensure commitment to this program.
This new approach to human factorshas the dual objectives of:
approve and direct fiscal resources
at specific human factorsprograms; and
maintain a corporate level focal
point to ensure human factorsprogram consistency, whileidentifying and reducing costlyduplication of effort.
The committee is comprised of seniormanagement from various operationaldivisions to ensure company widecommitment at a high level.
•
•
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EXPECTED BEHAVIOURS1.Knowledae Information and Strateqies 4.Proaress MonitorinCl
1.1 Demonstration of Knowledge Demonstrates required
4.1 Attending to Tasksdepth of know1edge from company and regulator
•Avoids allowing distractions to impact on operation;
publications.
•Checks creN and operational factors before creating duty
roster.1.2 Gathering of Information Gathers information from all available resources and operational areas.4.2 Analysis of Flight Progress
•Checks and recognises discrepancies between desired
1.3 Assessment of Information Recognises informationand actual flight status;
relevant and useful to the operation.•Systematically checks immediate and overall operational
objectives are being achieved;1.4 Structuring of Information Organises information in a•Ambiguities resolved without delay;
useful and consistent format relevant to the operation.•Errors shall be acknowledged, communicated and
resolved.1.5 Assessment/Selection of Strategies Assesses current plan and alternative plans. Decides on a timely and4.3 Response to New Informationappropriate course of action. Rehearses and reviews•Systematically gains additional information as required;
intended actions when situation requires.•Ascertains effect of information on operation;
•Reacts with appropriate actions to ensure neN
2.Crew Coordination
information does not have an adverse impact on2.1 Input of CreN Members
operation;
•Considers impact of changes on operation and reviews• Invites input from all creN;
strategies accordingly.• Assesses value of all input given;•
Actively participates in discussions on decisions;4.4 Controlling of Outcomes•
Communicates concern assertively when required; •Acts in accordance with designated crew role;• Provides effective support to pilot flying. •Demonstrates positive control of all aspects of
2.2 Sharing of Information/Plans/Strategies
operational responsibility in their area of responsibility.
•
States intended course of action dearly;4.5 Management of Errors•
Ensures other crew members understand communicated •Recognises and communicates observed error;information and proposed course of action;
•Assesses relevance and significance of error;•Briefs and shares all relevant information. •Utilises all relevant crew to minimise or negate impact of
error on the effective outcome of the operation;2.3 Consideration of Crew Needs •Recovers with a minimum loss of performance egotimely•
Considers own fitness and that of other creN membersresponse not concerned with irrelevant details.relevant to the operation; •
Considers experience and recency of creN in terms of4.6 Use and Monitoring of Automationtask assignment;•Demonstrates knO'Wledge of standard operational
•Recognises and resolves conflict;
procedures with respect to autoflight modes and• Uses diplom acy and tact in support of crew and their selection;welfare.•Utilises suitable autoflight modes relevant to situation
2.4 Distribution of Workload
and phase of flight;
•Confirms selected autoflight modes were achieving
•Delegates to avoid self or creN overload;
required and/or desired flight path.• Recognises required time to safely accomplish tasks;,~> •
Maintains awareness of effect of external pressures on5.Self Assessmentoperation; •
Anticipates and prepares for foreseeable operational 5.1 Acknowledgment of Performancerequirements.
•Discusses where improvements could be made in
personal and/or crew performance;3.ATC and NaviClation •Realistically assesses performance.
3.1 Optimise & Implement
5.2 Seeking of Feedback•Understands ATC instructions and questions those not •Recognises difference between own performance and
understood; required standard;• Cross checks instructions with planned or desired course•Actively seeks feedback;of action;
•Undertakes and maintains a programme to monitor and•
Follows accepted dearance except in emergencyimprove both self and crew performance.situations; •
Attempts to improve operational effectiveness throughvariations to clearances;•
Takes into account terrain, weather. and traffic when
requesting and accepting dearances;•Maintains awareness of other traffic in operational
vicinity."
• ~ ~OANTAS Flight TrainingDraft
Flight Crew Observation Record FT/11 •
Crew Resource Management
Customer Service
• FT11 (Jan 2001) Version 1.00
Comments
Integration of human factors training with safety
van Amermaete, J.A.G. (1998).NOTECHS: Non-technical skill
evaluation in JAR-FCL. National
Aerospace Laboratory NLR.
Captain Ian Lucas is the Group
General Manager Flight Operations
and Chief Pilot and currently operateson the B767. He has held various
training and managerial positions
within Qantas including Manager Line
Training, Manager Training 8767,
General Manager B744 Operations and
General Manager B737 Operations.
Or Graham Edkins is a qualified
accident investigator and holds
Masters and PhD degrees in
organisational psychology. He
currently manages the strategic
development of human factors
training, research and development
across the Qantas Group.
Helmreich, B. (2000). Culture and error:
The bridge from research to safety.
Paper presented at the IATA/lCAO
Flight Safety and Human Factors
Regional Seminar, Rio de Janeiro, 16-18
August.
ICAO (1993). Human factors digest
No. 10: Human Factors, Management
and organisation. International Civil
Aviation Organisation: Montreal,Canada.
The main objective of this article hasbeen to demonstrate that we take
human factors seriously at Qantas. In
most respects, human factors is thelast frontier in the battle to work safer
and smarter. This recognition at the
highest corporate level guaranteesthat human factors will become an
integrated way of life at Qantas.
References
•( EVENT BASED ,INFORMATION
Conclusion
Stage 5. Longiwdinal evaluation ofthe program
Any change program of this magnitude
needs to be measured against expected
improvements in operating safety and
efficiency. This is where academic
expertise has much to offer. To this
end we will commence in May this year
a joint Qantas/University of Newcastle
PhD scholarship to determine the
impact of the corporate program on
individual and organisational safety
and business objectives. To date the
aviation industry has yet to develop a
valid evaluation methodology for
assessing the effectiveness of human
factors training.
A strategy for the implementation of a
company wide human factors program
has been outlined. This program is
expected to take three years but the
payoff will be a more strategic method
of identifying major human risk factors
that may threaten core business
objectives.
The maturity of our aircrew body in
relation to human factors principles
means that gains in this area will
continue to be small but significant. It
is other operational areas within
Qantas, with less refined human
factors development, that hold the
greatest promise.
•...- ..
" ,"=-: ,"- .,
Observation is made with respectto crew/team behaviour not
individual behaviour.
Information on the observation
form will be de-identified.
Information recorded on the form
will be used to continuously
improve training needs across
each operational area rather than
identify training deficiencieswithin each individual.
Staff are assessed ONLY on those
expected behaviours that areobserved ie; if it is not observed itis not assessed.
(OPERATIONAL BASED'INFORMATION
•
•
•
Observation of expected behaviours
wi 11be conducted according to the
following core principles:
•
The expected behaviours will
essentially form a framework to
analyse performance at the individual,
divisional and organisational level,
which can then be compared to
behavioral data reported via safety
incidents and accidents, and through
scheduled audits. The integration of
these two historically isolated areas
of trend information will provide
Qantas with an enhanced ability to
identify the major human factors risks
to safety and efficiency across its
various operational areas. The
organisation of this system is
presented below.
I~IROUTE CHECK
CYCLIC TRAINING
16 Flight
Recommended