Human factor & safety - erasmusfsamp.org · Tolosa – 2007 ENGINE TEST Etihad •Inserire foto . Some notes… •Note 1.— For statistical uniformity only, an injury resulting

Human factor & safety

Roma – 21° September 2017 Capt. Antonio Chialastri © - www.stasa.it

Relatore Capt. Antonio Chialastri ©

HU MAN

FAC TOR

Kiev, 12/09/2017 Speaker: Antonio Chialastri – La Sapienza University - Rome

Operators as imagined


The real operators..


Some doubts...

•Is safety something?

•Is safety a theory?

•Is safety a methodology?

•Is safety a duty?

Four basic questions

•The ontological questions: What is safety?

•The epistemological questions: how do we know and measure it?

•The methodological question: how do we put it in practice?

•The ethical question: who and why should assure safety?

I. – the ontological question:

what is safety?

•How do we define something characterized by an absence?

•What do we mean with safety?

Some concepts about

safety and human factors

•Safety, Security, Emergency

•Accident, Incident, serious event

•Threat, Risk, Hazard

•Errors, Violations

•Conceptual frames for safety interpretation

Safety

Safety

•Relative freedom from danger, risk, or threat of harm,

injury, or loss to personnel

and/or property, caused by

accident or due to

unintentional errors.

Security

Security

•Also called social safety or

public safety, security

addresses the risk of harm due

to intentional criminal acts

such as assault, burglary or

vandalism

Emergency

Emergency •Sudden, unexpected, or impending situation that may cause injury,

loss of life, damage to the

property, and/or interference with

the normal activities of a person

or firm and which, therefore,

requires immediate attention and

remedial action.

What is risk? • Risk is an uncertain event or condition that, if it occurs, has an effect on at least one

objective. It is the probable frequency and

probable magnitude of future loss.

• The probability of something happening

multiplied by the resulting cost or benefit if

it does.

• The probability or threat of quantifiable

damage, injury, liability, loss, or any other

negative occurrence that is caused by external

or internal vulnerabilities, and that may be

avoided through preemptive action.

Systemic risk

Severity Frequency

Negligible Minor Major Dangerous Catastrophic

Frequent:

E ≥10-3

Likely:

10-3≤E≤ 10-5

Remote: 10-5≤ E ≤ 10-7

Very remote:

10-7 ≤ E ≤ 10-9

Extremely remote:

10-9< E

•Aviation is a socio-technical system very

dangerous, but with a low

risk

Risk as perceived

Real risk

Yellow light, light risk?

Psychological risk

•Risk expectancy

•Risk sensitivity

•Risk penalty

Hazard

•Performative hazard

•Boundary hazard

•Evolutionary hazard

Performative hazard

Messina – 28° July 2016 Capt. Antonio Chialastri © - www.stasa.it

Boundary hazard

Evolutionary hazard

Accident • An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which:

• 1) a person is fatally or seriously injured as a result of:

• A) Being in the aircraft, or —

• B) following any direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or

• C) due to direct exposure to jet blast, except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew;

• 2) the aircraft sustains damage or structural failure which: — adversely affects the structural strength, performance or flight characteristics of the aircraft, and — would normally require major repair or replacement of the affected component, except for engine failure or damage, when the damage is limited to the engine, its cowlings or accessories; or for damage limited to propellers, wing tips, antennas, tires, brakes, fairings, small dents or puncture holes in the aircraft skin; or

• 3) The aircraft is missing or is completely inaccessible.

Tolosa – 2007 ENGINE TEST Etihad

• Inserire foto

Some notes…

• Note 1.— For statistical uniformity only, an injury resulting in death within thirty days of the date of

the accident is classified as a fatal injury by ICAO.

• Note 2.— An aircraft is considered to be missing when the official search has been terminated and the

wreckage has not been located.

Serious incident

• An incident involving circumstances indicating that an accident nearly occurred.

• Note 1.— The difference between an accident and a serious incident lies only in the result.

• Note 2.— Examples of serious incidents can be found in Attachment C of Annex 13 and in the Accident/Incident

Reporting Manual (Doc 9156).

Incident • An occurrence, other than an accident, associated with the operation of an aircraft which affects or could

affect the safety of operation.

• Note.— The types of incidents which are of main interest to the International Civil Aviation

Organization for accident prevention studies are listed

in the Accident/Incident Reporting Manual (Doc 9156).

Causes and contributing factors

• Causes: actions, omissions, events, conditions, or a combination thereof, which led to the accident

or incident.

• Contributing factors are any behavior, omission,

or deficiency that sets the stage for an accident,

or increases the severity of injuries.

Threat

• Event that occurs beyond the influence of

the crew. It leads to an increase in the

operational complexity and requires proper

management in order to maintain adequate

safety margins.

• Example of inflight threats are: adverse

meteorological conditions, congested

airspace, aircraft malfunctions, errors.

Kind of threats

•Organizational

• Operational pressures

• Devices malfunctions

• Crew errors (due to poor training)

• Maintenance mistakes

• Ground staff errors

• Dispatch

• Documentation

•Environmental

• Weather

• Air traffic congestion

• Airport facilities

• Terrain

• Others (i.g.: similar

call signs)

Threats on ground

•Loading and unloading

•Dangerous goods

•Weight and balance

•Damages

•Jet blast

Unexpected threats:

Loading and unloading

Messina – 28° July 2016 Capt. Antonio Chialastri © - www.stasa.it

Weight and balance: wrong take off data

Flight MK 1605 – Halifax, Canada

Balance: U.S. cargo flight in

Afghanistan

Dangerous goods in the cargo hold: lithium batteries

Jet blast

Resources

•Competencies (technical & NO-TECHS)

•Knowledge

•Experience

•Motivation

•Technological aids

•Teamwork

Safety

=

Resources ≥ threats

Coffee break

Roma – 13 marzo 2017 lezioni master aviazione civile La Sapienza Capt. Antonio Chialastri © - www.stasa.it

II. – the epistemological question:

how do we know (and measure) the

safety level?

•Accidents’ investigation

•Safety models

•Reporting system

•Simulation

20

10

60 70 80 90 00

Loss of

control

20

15

10

5

0,5

II – Accidents’ trend

Paradigmatic accidents

•Tenerife 1977 (SHELL)

•Dryden 1989 (Reason’s model)

•September 11th 2001 (new security)

•Flight AF 447 (Resilience engineering)

•Germanwings case (?)

Root cause:

human performances and limitations

• Flying skills

• Fatigue

• Sleepiness

• Distractions

• Poor design

• High mental workload

• Jet lag

• Visual illusions

Indexes of depth’s perception

1


White out phenomenon

Foggy weather: RVR 100 mt.

Spiral or circle?

Perception of colors:

which is darker: A or B?

Runway in sight….

Sure?

Attention patterns


Concentration


Focusing


oops; disappeared


Vestibular apparatus


178 seconds of life.. • you entered a cloud apparently small…

• You feel in level flight, but the compass is increasing..

• you push on a pedal to stop it, but it let you feel uneasy, so you stop pushing the pedal

• Unfortunately the compass is still turning a little bit

faster than before. The speed indicator is increasing.

• You try to scan the instruments but you are not used to.

• Hopefully, in a few minutes you will get out of this cloud.

• Alas, you have not some minutes, but just seconds.


100 seconds of life..

• you are looking now at the altimeter and

chillingly you discover it is turning

anti-clockwise.

•Istinctively, you pull back the yoke (cloche).

•Suprisingly, the altimeter doesn’t stop turning.

•The engine RPM are now in the red band.

•The airplane speed is high, too


45 seconds of life

• Now you are sweating.

•What is wrong with the flight controls?

•Why is the speed increasing pulling back the yoke?

•The wind on the fuselage tells you that the speed should be high.


10 seconds of life..

• you exit the cloud and you are

looking at the terrain below you.

• trees are getting bigger.

• you may see the horizon only raising up your.

• you are flying upside down.

• you open your mouth to scream but…


Time is over....

•You are another victim of spatial

disorentation!!



Human problem……

Technological solution •Autopilot

•Flight director

•Auto-throttle

•Radar

•ILS

•Inertial platform

•……

20

10

60 70 80 90 00

CFIT

Loss of

control

Human problem:

poor teamwork • Situational awareness

• Leadership

• Top-down approach captain vs. poor assertiveness by the copilot

• Complacency

• Lack of critique

Accident rate/phase of flight


Tenerife accident

Cause • Situational awareness

• Teamwork inefficace

• Leadership

• Gerarchia esasperata

• Assertività

• Complacency

•Comunicazione


Solution: psychology

Selection

Cockpit Resource Management

Crew Resource Management

.....and GPWS too


Selection of pilots before

• Sensing (perception of a visual, acustic or sensorial datum

• Detecting (an object in the visual field);

• Discriminating or identifying an object differentiating

between figure and background);

• Coding (translating a stimolus in another. E.g. word,

imagines, etc.

• Classifying (giving a meaning to the object e.g. friend-foe

• Estimating (evaluation of distances, dimensions, shape, speed

• Sequencing when performing actions or procedures

• Logical ability (right application of calculus, problem

solving, euristics, etc.);

• Rule compliance;

• Decision making;

• Problem solving.

Dopo

• Communication skills

• Social competencies

• Empathy

• Conflict resolution

• Leadership 9.9

• Balance


SHELL

Human problem…

psychological solution Pilots started to be selected..

Trained to good teamwork

Cockpit Resource Management/ Crew

Resource Management

Evaluated for their non technical

skills

GPWS helped, too..

Cockpit Resource Management

http://img684.imageshack.us/i/leadershipgrid.jpg/

20

10

60 70 80 90 00

Loss of

control

CFIT

20

15

10

5

0,5

American

De-

regulation

II - La curva degli incidenti

Problem: organizational issues •1980: «Happiness is a cheap seat»

•Protection vs. production

•Cuts to maintenance, training, investment.

•Production vs. protection

•NASA is managed according to the mantra: cheaper, faster, better…

•Drift to danger: Alaska 261

•1985: «Happiness is a safe seat»..


L’incidente di Dryden


Human problem…

solution: stricter rules

•Flight time limitations

•Better checks by the regulator

•More frequent maintenance checks

•1990: Reason’s model..


Technological protections

Reckless actions

Human factor

Pre-conditions

Management

Accident

Top management Political deicsions

Reason’s model

Latent conditions

Active failures


Cheaper, faster, better….


20

10

60 70 80 90 00

Loss of

control

CFIT Loss of

control

20

15

10

5

0,5

American

De-regulation

La curva degli incidenti

Problem:

human-machine interaction

• Complacency

• Poor manual skills

• Ironies of automation (S. Bainbridge)

• Situation awareness

• Opaqueness

• Fundamental surprise vs. situational surprise

Human problem

solution: Ergonomics

• Human factor experts are involved at the early stage of systems design;

• Designer must focus not only on

usability but on a wide range of issues

are taken into consideration: physical,

cognitive, social.

• But there is still a long way to go....

User-friendly

What did the poet want to express?

F-111: how do pilots think?

strangely!

Social ergonomics:

A-320/A330

System induced negative transfer

Tunintair case:

ATR – 42 vs ATR – 72 fuel indicator


System-induced negative transfer:

Crossair Accident in Zurich


Air France 447

20

10

60 70 80 90 00

Loss of

control

CFIT Loss of

control

20

15

10

5

0,5

American

De-

regulation

La curva degli incidenti

Unlawful

interference

Roma – 6 ottobre 2016 Capt. Antonio Chialastri © - www.stasa.it

95

Is it the only case?


• Japan Airlines (psychiatric problems) - 1979

• Air Maroc (relationship broken) - 1994

• Silk Air (economical issues) - 1997

• Egyptair 990 (disciplinary consequences) – 1999

• Jet Blue(Captain)- 2012

• Air Namibia (Divorce in progress) - 2013

• Ethiopian Airlines (political asylum) - 2014

• Malaysia MH 370 (?) - 2014

• Germanwings – (burn-out?) 2015

Pilot’s wilful actions..


Human problem..

Solution: ?

•Two persons in cockpit

•Psychological tests

•Stricter control on drugs and alcohol abuse

•Special training for doctors checking the pilots

•Trade-off between privacy and common good

•Peer support


Some proposals to avoid…

1.Human factors as all rounded

discipline

2.Better industrial relationship

3.Stop pay-to-fly

4. Training focused on resilience


Detect •1) Psychiatric assessment and psychological tests

•2)Social control

•3)Internal survey

•4) Data repository


MITIGATE

•1)May a pilot assume psycho-active substances?

•2) PEER SUPPORT


Some highlights..

• Safety improves……..and decreases

• Threats change nature over time.

• Today’s solutions could become tomorrow’s problems

• In a complex system safety is not once and for all

• Human being is either a resource or a threat

• Human factor studies should focus on the entire pilot’s life and not only to the non technical

skills(NOTECHS)


Thank you for your attention


Three afterthoughts....

• Safety may improve and….may decrease

• Threats continuously change

• We’ll never reach zero accidents

Thank you for your

attention

•[email protected]

•3888714486

mailto:[email protected]

Documents

Human factor & safety - erasmusfsamp.org · Tolosa – 2007 ENGINE TEST Etihad •Inserire foto . Some notes… •Note 1.— For statistical uniformity only, an injury resulting