Presented to: T BAA By: Tampa FAASTeam Date: April 17, 2013 Federal Aviation Administration Federal...

Presented to: T BAA

By: Tampa FAASTeam

Date: April 17, 2013

Federal AviationAdministration

• Federal Aviation• AdministrationSafety Stand Down

Building a Safety Community

Safety Stand Down 2013

April 17, 2013

Agenda

0745 – 0845 Breakfast

0845 - 0950 Welcome and Introductions

0950 - 1000 Break

1000 – 1050 Human Factors

Dr. Karen D. Dunbar

1050 – 1100 Break

1100 – 1200 Loss of Control

Dennis H. Whitley

1200 – 1245 Lunch

1245 – 1300 Tribute To Flight Attendants

1300 – 1445 Miracle on the Hudson

Doreen Welsh

1445 – Closing remarks - Adjourn

April 17, 2013

Welcome

• Exits• Restrooms• Emergency Evacuation• Breaks • Sponsor Acknowledgment• Other information

April 17, 2013

Sponsors

Landmark Aviation

Tampa Air Traffic Controllers

Tampa International Airport Fire Department

Tampa Jet Center

West Star Aviation

WINSLOW Life Raft

World Fuel

April 17, 2013

Tampa FSDO Personnel• Amanda Cromie

– FSDO Manager

• Jose Figueroa– Front Line Manager

• Patrick Seggerman– Front Line Manager

• James Minary– FAASTeam Program Manager

April 17, 2013

Florida FSDO Borders

• Alabama FSDO SO09

• North Florida FSDO

• SO15 & SO35 • South

Florida FSDO SO19

April 17, 2013

• North Florida

FSDO SO35

Florida FSDO Borders

Tampa FSDO

Orlando FSDO

April 17, 2013

FSDO Information– CFI and DPE Oversight– Flight Schools– Charter Companies– Film Production– Accidents & Incidents– Complaints– Repair Stations – Mechanic Schools– IA Mechanics – Special Flight Permits– Field Approvals

April 17, 2013

Contact us

• http://faa.gov• Field & Regional Offices• Flight Standards District Offices (FSDO)• Select State• Select Office

April 17, 2013

Wings Credits• 3 Knowledge Credits for this Stand Down

– Preregistered?• Initial roster

– Not Preregistered?• Sign in with legible faasafety.gov email

• No Account?– See a Rep today

April 17, 2013

The Safety Stand Down

• Military Origins– Response to Safety Issue– Temporary Operations Halt– Devote time to Safety

April 17, 2013

The Safety Stand Down• Human Factors

– Investigates interaction between humans and systems– Evaluates fit between user, equipment and environment– Considers capabilities and limitations – Focus on task, demands, equipment and information

• Loss of Control– Number 1 Factor in fatal accidents

• Appch. & Ldg. LOC Workgroup– Findings & Recommendations

» Technology» Human Factors

April 17, 2013

LOC Workgroup Findings

• Lack of single – pilot CRM skills• Unstabilized approaches• Flight after extended periods of not flying• Inappropriate go-around procedures• Insufficient transition training• Over reliance on automation• Flight after use of drugs• Lack of Aeronautical Decision Making Skills

April 17, 2013

FAA Information Session• Presented by:

– FAA Southern Region– Tampa Florida FAASTeam

April 17, 2013

Introduction to Human Error

• Presented by:Dr. Karen D. Dunbar

FAA Safety Team

Representative

Federal AviationAdministrationHuman Error

Making Sense of Accident Reports

Presented to:

FAASTeam 2013 Safety Stand Down

April 17, 2013

Overview

• Error Fundamentals• System aspects of error• Application of Error Fundamentals

• Gold Seal Key Concepts

SSD 2013

April 17, 2013

A. Human

B. Universal

C. Inevitable

D. A bad thing

To Err is:

April 17, 2013

In so far as I am able, I agree to suspend thoughts of judgment and retribution with respect to the characters in the stories I am about to hear or relate; and to the presenter of this seminar. I will seek to understand why events occur rather than to identify and punish those

Certificate of Agreement Safety Stand Down 2013

SSD 2013

who were responsible for those occurrences. I understand that this agreement has no legal effect whatever and, in any case, applies only during this seminar unless I choose to continue with this way of thinking in the future.

April 17, 2013

The 5 Ws

April 17, 2013

The 6th W

What’s to be done about it?

April 17, 2013

Four questions are easy

April 17, 2013

The Accident Report

Probable Cause

Safety Recommendation

April 17, 2013

The Accident Report

Moose on Field

Moose proof fence

April 17, 2013

Hindsight Bias

HindsightOutside

Violation

Breakdown

Lost the Bubble

Failure

Bad Judgment

Incident EvolutionTime(Sidney Dekker 2006)

April 17, 2013

Incident EvolutionTime

Inside

-Easy-Profitable

-Loyalty

-Prod-uctive

-Flexible

-CommonSense-Better -Skill

-Creative-Perfect

-Good Idea-Judgment-Experience

-BestOption-Quick

(Sidney Dekker 2006)

Hindsight Bias

SSD 2013

April 17, 2013

Ever have one of those days?

• Take a wrong turn on a familiar route

• Set out for work when you intended to go to the store

• Lock keys in car or house

• Can’t find the keys to lock in car or house

April 17, 2013

People cannot easily avoid those actions they did not intend to commit

James Reason & Alan Hobbs (2003)

SSD 2013

April 17, 2013

Blaming people for their errors is emotionally satisfying but remedially useless.

We’re still accountable for our mistakes though.

April 17, 2013

Mikey’s story• Late night with interrupted sleep• Altered routine• Preoccupation with work

• How big an error?– Consequence was huge– Error was common

April 17, 2013

SSD 2013

We all operate within systems

Sometimes without knowing it

April 17, 2013

Vehicular Child Fatalities

Passenger Side Airbags vs Hyperthermia

Deaths

April 17, 2013

Deaths

April 17, 2013

Deaths

April 17, 2013

Accident Chain of Events

April 17, 2013

Accident Chain of Events

April 17, 2013

Accident Chain

Unsafe Acts

Preconditions

Cultural Influences

April 17, 2013

Unsafe Acts

Cultural Influences

Preconditions

Leaving Mikey in car

April 17, 2013

Pre-conditions

Cultural Influences

Pax side airbag

Fatigue

Warm Weather

Preoccupation Leaving Mikey in car

Sleeping Child

April 17, 2013

Cultural Influences

Child care responsibility

Work ethicPax side airbag

Fatigue

Sleeping Child

Warm Weather

Preoccupation Leaving Mikey in car

April 17, 2013

Child care responsibility

Work ethicPax side airbag

Fatigue

Warm Weather

Preoccupation

Safety significant errors can occur at all levels of the system

Leaving Mikey in car

Sleeping Child

April 17, 2013

The Swamp

Unsafe Acts

Preconditions

Cultural Influences

Adapted from Reason (1990)

April 17, 2013

Adapted from Reason (1990)

Coming Soon

Bayou Junction Housing Development

Unsafe Acts

Preconditions

Cultural Influences

April 17, 2013

People

Structure/Organization

Technology

The General Aviation System

April 17, 2013

U.S. General AviationSource NTSB

Accidents=Approximately 7/100,000hrs

Fatal Accidents=Approximately 2/100,000hrs

April 17, 2013

Human Error is Both Universal and Inevitable

It is the Downside of Having a Brain

SSD 2013

April 17, 2013

A Simplified “Blueprint” of Mental Functioning

Input Functions

Senses

Feedback Loops

Filter

(Attention)

Conscious Workspace

Long-term memory

(Knowledge base)

Output Functions

Hands, Feet, etc.

April 17, 2013

Conscious Workspace Long-term Memory

General Problem Solver

Limited Capacity

Contents Available

Sequential Processing

Slow and Laborious

Essential for new Tasks

Vast Collection of Programs

No Limits to Size or Duration

Unconscious

Parallel Processing

Rapid and Effortless

Handles Familiar Routines and Habits

Trial and Error Programming

April 17, 2013

Conscious Work Space

April 17, 2013

Long-term Memory

2 + 2 = …..

knock knock “...................?”

Mary had ..................

The sky is ……..

Grass is …..

April 17, 2013

Lnog-trem Meromy porgarms rley haevly on vsuisaul ifnoramiton and ptatren rcoegiontin hbaets.

Plitos are paticrculry aedpt at ptatren rcoegiontin and ulusaly taht wokrs wlel for tehm but oaccsillony taht hmaun tenendcy cuseas prelombs.

Rnunnig a falmialr porgarm in rospense to a difefernt stitauion or rnunnig a corrcet porgarm ipormprely can rsuelt in dsisater.

We are creatures of hbaet

SSD 2013

April 17, 2013

Count the F’s

FINISHED FILES ARE THE RESULT

OF YEARS OF SCIENTIFIC

STUDY COMBINED WITH THE

EXPERIENCE OF MANY YEARS

April 17, 2013

Count the F’s

April 17, 2013

Count the F’s

3 or 6?

April 17, 2013

Choice Point needing conscious attention

New Path

Wrong Path Taken

Usual Onward Path

Skill-based Slip

Highly Routine Sequence

April 17, 2013

Directly to Work

Mikey’s story

Turned left at Pereira Drive He should have turned

right at Pereira

Day Care Then work

His office's parking lot at the Department of

EducationFrom: Home

To: Work

April 17, 2013

People cannot easily avoid those actions they did not intend to commit…

SSD 2013

but they can gain a better understanding of when they’re likely to err.

April 17, 2013

Error/Environment Logging

Log errors by date

Describe environment

Include health, fatigue, stress

Look for patterns

April 17, 2013

Stress

Walking the line

8 In.20 Ft.

April 17, 2013

Stress

Walking the line

April 17, 2013

Extreme Stress Makes You StupidP

Increasing Stress

April 17, 2013

Managing the Managable

2 hour flight @ 10 gph. = 20 gal.

+ 1 hour reserve = 30 gal.

Fuel on board = 25 gal.

April 17, 2013

Managing the Managable

Call for fuel & top off

Enough fuel for the return trip

Just enough time to make the luau

Launch with the fuel you haveAmple time before meeting

Must fuel before return

Consider ditching evil partner

April 17, 2013

A. What?

B. Why?

C. When?

D. What’s to be done about it?

The Ws that are hardest to answer are:

April 17, 2013

A. PCs but not MACs

B. Conscious Workspace

C. Long Term Memory

D. MACs but not PCs

Programming is an attribute of:

April 17, 2013

A. NTSB & FAA Investigations

B. Central Nervous System

C. Long Term Memory

D. Conscious Workspace

“Trial and Error” is an attribute of:

April 17, 2013

Winners never quit ……

Quitters never….

Plan the flight & ……

You’ll never get anywhere if you don’t have a ….

When in doubt; stick to the ……

April 17, 2013

Get-there-itus

Plan Continuation Bias

“The continuation of an original plan even with the availability of information that suggests that the plan should be abandoned.”

April 17, 2013

If the flight’s not conforming to the plan …..

It doesn’t pay to wait for things to get better.

Address small problems early

Before they become big ones

SSD 2013

April 17, 2013

Errors are not intrinsically bad

We are “hardwired” to make errors

Bad News Good News

April 17, 2013

The Recipe for Disaster

Human Error + Unforgiving Activity= Disaster

April 17, 2013

You cannot change the human condition,

but you can change the conditions in which humans work. (and play)

April 17, 2013

How many people?

April 17, 2013

or this one ….. ?

April 17, 2013

583 fatalities – 64 survivorsTenerife 27 March 1977

The Best People Tend to Make the Worst Mistakes

SSD 2013

April 17, 2013

Many Errors Fall into Recurrent Patterns

April 17, 2013

One More Thing

•Confirmation Bias

April 17, 2013

One More Thing

Confirmation Bias

Common-sense Consistent Capable CorrectCoherent Clever

Other Drivers

Ignorant IneptIdiot IncompetentImpolite Ill-mannered

Fundamental Attribution BiasJames Reason & Alan Hobbs (2003)

April 17, 2013

• James Reason & Alan Hobbs (2003)

SSD 2013

You can’t understand why accidents happen if you assume the pilots involved were idiots.

April 17, 2013

A. Confirmation?

B. Hindsight?

C. Plan Continuation?

D. Fundamental Attribution?

The human biases that may negatively influence accident investigations are:

April 17, 2013

A. Anti-authority attitude

B. Sense of invulnerability

C. Past record of performance

D. Confirmation Bias

The best people make the worst mistakes because of their:

April 17, 2013

A. The Preconditions level

B. The Unsafe Acts level

C. All levels

D. Cultural Influences level

Safety-significant errors can occur at _______ of the system:

April 17, 2013

A. Should be avoided

B. Improve performance

C. Inhibit performance

D. Require medication

Moderate stress levels:

April 17, 2013

A. Lowest - Highest

B. Highest - Lowest

C. Lowest - Appropriate

D. Appropriate - Highest

Effective interventions should target the _______ level, but are usually most effective at the _____ level of a system.

April 17, 2013

Reading List• Managing Maintenance Error

– James Reason and Alan Hobbs

• Set Phasers on Stun and The Atomic Chef– Steven Casey

• Understanding Human Error– Sidney Dekker

• Deep Survival– Laurence Gonzales

• The Limits of Expertise– Key Dismukes

• Sway– Brafman & Brafman

April 17, 2013

Up next:

April 17, 2013

Up next:

Loss of Control

April 17, 2013

Up next:

Let’s take a little break

Loss of Control

April 17, 2013

Loss of Control Panel

Moderated by:Dennis H. Whitley

FAA Safety Team

Lead Representative

April 17, 2013

Loss of Control Panelists• Mr. Jack Tunstill

– CFII St. Petersburg

• Mr. Mike Windiman – CFII Plant City

April 17, 2013

Fatal LOC Accidents 2001-2010

LOC Accidents 10-Year Period

April 17, 2013

The PAVE Checklist

• Pilot• Aircraft• enVironment• External Pressure (s)

April 17, 2013

LOC Panel Case Study Number 1

• Pilot– Private Pilot– Total Time ……319– Time in type …. 1

• Aircraft– Jodel D-9

April 17, 2013

• enVironment– General Dewitt Spain, TN (M01)– Runway 16/34 225 MSL 3,800 x 75’– Left Base to Final Runway 34 – Weather (MEM – 11 nm SSE)

• VFR Few @ 7,000/10 SM• Wind Variable @ 3

April 17, 2013

Discussion

April 17, 2013

• Pilot– Private Pilot– Total Time ……604– Time in type ….248

• Aircraft– Cirrus SR 22

April 17, 2013

• enVironment– Aero Plantation, NC (NC21)– Runway 6/24 634 MSL 2400 x 60’– Left Base to Final Runway 6 – Weather (EQY – 6.5 nm East)

• Wind 320@11, Gust 22

April 17, 2013

310@11, G22

April 17, 2013

• Parachute– Deployed, but not fully

extracted.

• Autopsy Findings– Diphenhydramine– Pseudoephedrine– Zolpidem

April 17, 2013

Discussion

April 17, 2013

• Pilot– Private Pilot– Total Time ……975– Time in type ….44

• Aircraft– TBM 700

April 17, 2013

• enVironment– Cobb County Field, GA (KRYY)– Runway 9/27 1078 MSL 6311x100’– Final Approach to Runway 9 – Weather

• 5,500 BKN, 10 SM• Wind 120@6

April 17, 2013

• Autopsy Findings– Alfuzosin

• Prostate

– Bisoprolol *• Beta blocker

– Quinine• Arthritis

– Tramadol• For moderate to severe pain

* Known to AME

April 17, 2013

Discussion

April 17, 2013

Dedication

Niel Armstrong 1930 - 2012

April 17, 2013

The End?• Safety never ends

– Assess & manage risk– Train to maintain – Set the example

• You are vital members of the safety community– Continue on course– Climb to greater heights– Invite others to join

Presented to: T BAA By: Tampa FAASTeam Date: April 17, 2013 Federal Aviation Administration Federal...

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