Presented to: T BAA By: Tampa FAASTeam Date: April 17, 2013 Federal Aviation Administration Federal Aviation Administration Safety Stand Down 2013 Building

Presented to: T BAA

By: Tampa FAASTeam

Date: April 17, 2013

Federal AviationAdministration

• Federal Aviation• AdministrationSafety Stand Down

2013

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

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April 17, 2013


Welcome

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

3


April 17, 2013


Sponsors

Altra Medical

DJ Public Relations Inc.

ExecuJet Charter Service

Federal Aviation Administration

Federal Aviation Administration Safety Team

Hillsborough County Aviation Authority

JETEX Flight Support

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April 17, 2013


Sponsors

NBAA

OSI Restaurant Partners LLC

Rockwell Collins

St. Petersburg - Clearwater Int. Airport

Standard Aero

Signature Flight Support

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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

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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

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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

SO35

Orlando FSDO

SO15


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

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April 17, 2013


Contact us

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

11

http://faa.gov/


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

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April 17, 2013


13

1


April 17, 2013


The Safety Stand Down

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

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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

15


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

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April 17, 2013


FAA Information Session• Presented by:

– FAA Southern Region– Tampa Florida FAASTeam

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April 17, 2013


Introduction to Human Error

• Presented by:Dr. Karen D. Dunbar

FAA Safety Team

Representative

18

Federal AviationAdministrationHuman Error

Making Sense of Accident Reports

Presented to:

FAASTeam 2013 Safety Stand Down

19


April 17, 2013


Overview

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

• Gold Seal Key Concepts

SSD 2013

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April 17, 2013


A. Human

B. Universal

C. Inevitable

D. A bad thing

To Err is:

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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.

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April 17, 2013


The 5 Ws

Who

What

When

Where

Why

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April 17, 2013


The 6th W

Who

What

When

Where

Why

What’s to be done about it?

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April 17, 2013


Four questions are easy

Who

What

When

Where

Why


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April 17, 2013


The Accident Report

Who

What

When

Where

Probable Cause

Safety Recommendation

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April 17, 2013


The Accident Report

Who

What

When

Where

Moose on Field

Moose proof fence

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April 17, 2013


Hindsight Bias

HindsightOutside

Violation

Breakdown

Lost the Bubble

Failure

Error

Bad Judgment

Incident EvolutionTime(Sidney Dekker 2006)

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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

29

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

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April 17, 2013


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

James Reason & Alan Hobbs (2003)

SSD 2013

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April 17, 2013




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

We’re still accountable for our mistakes though.

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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

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April 17, 2013



SSD 2013

We all operate within systems

Sometimes without knowing it

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April 17, 2013


Vehicular Child Fatalities

Passenger Side Airbags vs Hyperthermia

Deaths

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April 17, 2013




Deaths

36


April 17, 2013




Deaths

38

37


April 17, 2013


Accident Chain of Events

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April 17, 2013


Accident Chain of Events

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April 17, 2013


Accident Chain

Unsafe Acts

Preconditions

Cultural Influences

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April 17, 2013


Unsafe Acts

Cultural Influences

Preconditions

Leaving Mikey in car

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April 17, 2013


Pre-conditions

Cultural Influences

Pax side airbag

Fatigue

Warm Weather

Preoccupation Leaving Mikey in car

Sleeping Child

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April 17, 2013


Cultural Influences

Child care responsibility

Work ethicPax side airbag

Fatigue

Sleeping Child

Warm Weather

Preoccupation Leaving Mikey in car

43


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

44


April 17, 2013


The Swamp

Unsafe Acts

Preconditions

Cultural Influences

Adapted from Reason (1990)

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April 17, 2013


Adapted from Reason (1990)

Coming Soon

Bayou Junction Housing Development

Unsafe Acts

Preconditions

Cultural Influences

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April 17, 2013


People

Structure/Organization

Technology

Tasks

The General Aviation System

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April 17, 2013


200

01950

196

0 197

0 198

0 199

0

U.S. General AviationSource NTSB

0

10

20

30

40

50

60A

ccid

ents

/100

,000

flig

ht

ho

urs

Accidents=Approximately 7/100,000hrs

Fatal Accidents=Approximately 2/100,000hrs

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April 17, 2013


Human Error is Both Universal and Inevitable

It is the Downside of Having a Brain


SSD 2013

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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.


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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

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April 17, 2013


A

CBCB

A

Conscious Work Space

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April 17, 2013


Long-term Memory

2 + 2 = …..

knock knock “...................?”

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

The sky is ……..

Grass is …..

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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

54

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

55


April 17, 2013


Count the F’s





56

3?


April 17, 2013


Count the F’s





57

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

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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

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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.

60


April 17, 2013


Error/Environment Logging

Log errors by date

Describe environment

Include health, fatigue, stress

Look for patterns

61


April 17, 2013


Stress

Walking the line

$

6 In.

8 In.20 Ft.

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April 17, 2013


Stress

Walking the line

63


April 17, 2013


Extreme Stress Makes You StupidP

erfo

rman

ce

Increasing Stress

Per

form

ance

Increasing Stress

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April 17, 2013


Managing the Managable

2 hour flight @ 10 gph. = 20 gal.

+ 1 hour reserve = 30 gal.

Fuel on board = 25 gal.

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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

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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:

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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:

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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:

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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 ……

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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.”

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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

72


April 17, 2013


Errors are not intrinsically bad

We are “hardwired” to make errors

Bad News Good News


73


April 17, 2013


The Recipe for Disaster

Human Error + Unforgiving Activity= Disaster

74



April 17, 2013



You cannot change the human condition,


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

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April 17, 2013


How many people?

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April 17, 2013


or this one ….. ?

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April 17, 2013


583 fatalities – 64 survivorsTenerife 27 March 1977

The Best People Tend to Make the Worst Mistakes

SSD 2013

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April 17, 2013



Many Errors Fall into Recurrent Patterns

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April 17, 2013


One More Thing

•Confirmation Bias

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April 17, 2013


One More Thing

Confirmation Bias

You

Common-sense Consistent Capable CorrectCoherent Clever

Other Drivers

Ignorant IneptIdiot IncompetentImpolite Ill-mannered

Fundamental Attribution BiasJames Reason & Alan Hobbs (2003)

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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.

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April 17, 2013


A. Confirmation?

B. Hindsight?

C. Plan Continuation?

D. Fundamental Attribution?

The human biases that may negatively influence accident investigations are:

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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:

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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:

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April 17, 2013


A. Should be avoided

B. Improve performance

C. Inhibit performance

D. Require medication

Moderate stress levels:

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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.

87


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

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April 17, 2013


Up next:

89


April 17, 2013


Up next:

90

Loss of Control


April 17, 2013


Up next:

91

Let’s take a little break

Loss of Control


April 17, 2013


Loss of Control Panel

92

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

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April 17, 2013


Fatal LOC Accidents 2001-2010

94

Man

euve

ring

App

roac

h

En

rout

e

Init.

Clim

b

Unk

now

n

Tak

e O

ff

Unc

ontr

olle

d D

esce

nt

Land

ing

Em

er.

Des

cent

Em

er.

Land

ing

Em

er.

Aft

er T

.O.

LOC Accidents 10-Year Period

0

50

100

150

200

250

300

350


April 17, 2013


The PAVE Checklist

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

95


April 17, 2013


LOC Panel Case Study Number 1

96

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

• Aircraft– Jodel D-9


April 17, 2013



97

• 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

http://skyvector.com/?ll=35.200694444,-90.053972222&chart=115&zoom=3


April 17, 2013


Discussion

98


April 17, 2013



99

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

• Aircraft– Cirrus SR 22


April 17, 2013



100

• 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


101

310@11, G22


April 17, 2013



102

• Parachute– Deployed, but not fully

extracted.

• Autopsy Findings– Diphenhydramine– Pseudoephedrine– Zolpidem


April 17, 2013


Discussion

103


April 17, 2013



104

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

• Aircraft– TBM 700


April 17, 2013



105

• 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


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April 17, 2013



107

• Autopsy Findings– Alfuzosin

• Prostate

– Bisoprolol *• Beta blocker

– Quinine• Arthritis

– Tramadol• For moderate to severe pain

* Known to AME


April 17, 2013


Discussion

108


April 17, 2013


Dedication

Niel Armstrong 1930 - 2012

109


April 17, 2013


110

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

Documents

Presented to: T BAA By: Tampa FAASTeam Date: April 17, 2013 Federal Aviation Administration Federal Aviation Administration Safety Stand Down 2013 Building