Overcoming Human Factors by Retraining: What is Next for Crew Members After a Mishap Investigation? by Captain Paul Miller.

Overcoming Human Factors by Overcoming Human Factors by Retraining: Retraining:

What is What is NextNext for Crew for Crew Members Members

After a Mishap Investigation? After a Mishap Investigation? by Captain Paul Millerby Captain Paul Miller

Overcoming Human Factors by Overcoming Human Factors by Retraining: Retraining:

What is What is Next Next for Crew for Crew Members Members

After a Mishap Investigation? After a Mishap Investigation? by Captain Paul Millerby Captain Paul Miller

Welcome to the 24th European Welcome to the 24th European Aviation Safety SeminarAviation Safety Seminar

Dublin, IrelandDublin, Ireland

February 29 - March 1, 2012February 29 - March 1, 2012

partnership betweenpartnership between

European Advisory Committee, European Advisory Committee, Flight Safety Foundation Flight Safety Foundation

EurocontrolEurocontrol

European Regions Airline Association European Regions Airline Association

Problem in a rhyme:Problem in a rhyme:What do you do,What do you do,with members of the Flight Crewwith members of the Flight Crewafter the Boards are through?after the Boards are through?You are faced with the taskYou are faced with the taskOf how to renewOf how to renewWhat has unexpectedly gone askew?What has unexpectedly gone askew?When assets are few,When assets are few,with no set course to pursue,with no set course to pursue,what do you do?what do you do?

Retraining is a cluethat will work for you

to plan a syllabusof human factors

improoo

improvement.

Problem:Good crew - remember that the company assigned them to the flight, as fully qualified, fully certified, fully competent, totally checked out when they began their assignment. [If they were “screwed up” as alleged, why were they assigned to operate the flight?]

Problem:Good crew

HF particular & specific human error

Possibly loss of certification by regulator

No plan for recertification

No plan for human factors retraining

No plan tailored to this particular flight crew, who have this particular & specific HF problem

Problem:

HF human errorPossibly loss of certification by regulatorNo plan for recertificationNo plan for human factors retrainingNo plan tailored to this particular

flightcrew, who have this particular & specific HF problem

Problem = Need:

HF human errorPossibly loss of certification by regulatorNo plan for recertificationNo plan for human factors retrainingNo plan tailored to this particular

flightcrew, who have this particular & specific HF problem

Need:

Plan for recertification

Plan for human factors retraining

Plan tailored to this particular flight crew, who have this particular & specific HF problem

Need:

Plan for tailored HF retraining

Need:

Plan for tailored HF retraining

To prepare for recertification if needed

Why

tailored HF retraining?

Why

tailored HF retraining?

Is it the same as recertification?

Why

tailored HF retraining?

Is it the same as recertification?

[remember that this crew was certified at their current level of HF skill]

Why

tailored HF retraining?Is it the same as recertification?[remember that this crew was certified at

their current level of HF skill]Most likely the Mishap Investigation

revealed “pilot error”

Why

tailored HF retraining?Is it the same as recertification?[remember that this crew was certified at their

current level of HF skill]Most likely the Mishap Investigation revealed

“pilot error” that is, a human factors deficiency

Why

Recertification may or may not include a human factors element

Why?

Recertification may or may not include a human factors element

But this crew achieved certification previously but did so without achieving or maintaining competency in HF skills

Why?

therefore, the deficiency was in HF, not in certification

Therefore, recertification alone will not address the HF deficiency.

Why?

Even if dismissed from one company, the crew may get recertified and work for another company

Still with the HF deficiency

Why?

If not dismissed, the crew may get recertified and work for the same company

But, …still with this particular & specific HF deficiency

Why?

If not dismissed, the crew may get recertified and work for the same company

But, …still with this particular & specific HF deficiency … another mishap waiting to happen?

Remember

If charges of the regulatory administrative investigation are true…

If the charges of the criminal investigatgion are true…

If the charges of the accident investigation board are true….

Remember

Then the airman/men had gained certification once already…

Having done so with the current HF deficiencies...

Remember

Therefore the airline policy of “dismiss and replace”

And the regulatory policy of “sanction and recertify”

May never address the human factors deficiency

Remember

Therefore the airline policy of “dismiss and replace”

And the regulatory policy of “sanction and recertify”

May never address the human factors deficiency and is not a good solution.

Training is Learning

We learn from our mistakes?Keep the mishap crew?Didn’t realize that they were making a

human errorEducate other flight crew to recognize

the problem, take correct action, avoid a mishap

Accident vs Mishap

Accident

-event of chance

-event outside of human control

-uncertainty

-probability

Mishap-event of human

action/inaction-linked directly to

human behavior-preventable

Accident vs Mishap

Accident

-event of chance

-event outside of human control

-uncertainty

-probability

Mishap-event of human

action/inaction-linked directly to

human behavior-preventable

Accident vs Mishap

Accident

-event of chance

-event outside of human control

-uncertainty

-probability

Mishap-event of human

action/inaction-linked directly to

human behavior-preventable

Safety Style Mishap Investigation

Finds:

-Human factors

-Human errors

Recommends Changes:

-prevent that error, that factor from being made by another crewmember again

Safety Theory

As human errors are decreased…

…the introduction of safety hazards are decreased

…Safety Theory

As safety hazards are decreased …

…mishaps will be decreased

Tailored Retraining

Decrease human factors in commercial aviation by increased human factors training…

…mishaps will be decreased towards zero in commercial aviation

Tailored Retraining derives from Safety Investigation only

-not from a Legal accident board investigation

-not from a Criminal and /or Civil Investigation

-not from an Administrative Regulatory Certification Hearing

-not from an FAA Part 709 Ride

Tailored Retraining derives from Safety Investigation only

Seek cause of the mishap

Offer recommended corrective actions that would have prevented this mishap

Legal Accident Board Investigations

Seek evidentiary reasons to find blame for property damage and personal injury suffered

Documents source for further litigation form compensation and punishment

Legal Accident Board Investigations

Seldom recommend course of action for crew involved

Admin-Regulatory Certifications

Airman Certificate

-suspend

-revoke

-reinstate

No course of action to prevent recurrence of mishaps

FAA Part 709 Rides

Intended to weed out weak crew members and revoke certification

Not intended to retrain crew who possess a HF weakness, such as in judgment

Human Factors Studies focus on frailties of…

-judgment

-decision making

-behavior

-communications skills

-attitude

-stress

Human Factors Studies focus on frailties of…

-fatigue

-loss of situational awareness

-interpretation of data

-crew resource management, working together well

Tailored Retraining focuses on how and why human frailties led to

-failure to use already established standard operating procedures (SOP)

-why, even with a very high level of compliance of SOP, some crew still do not comply at times

Tailored Retraining focuses on how and why

-and even a few do not comply at all….

-except during check rides and training events

Tailored Retraining is able to reach through the thought process

-For those few for whom normal training does not

-improve their compliance with SOP

-addressing HF, human error, pilot error specifically

Tailored Retraining is not

-procedural recertification to reacquire airman certificates lost

-regular training set up to build on basic skills developed in basic training

Linking Mishap Investigation to Tailored Retraining

-Derived from finding of facts and analysis of crew errors causing the mishap,

-Deviations from the normal procedures, practices and techniques.

Linking Mishap Investigation to Tailored Retraining

-Conclusions, that if followed would have prevented mishap

-Deviations from the normal procedures, practices and techniques.

Linking Mishap Investigation to Tailored Retraining

-Clearly defined steps that will prevent the mishap from recurring

-Adapts steps into custom tailored individualized HF retraining

Linking Mishap Investigation to Tailored Retraining

-Adapting tailored retraining from non0mishap investigations is essentially the same

-incidents, other hazardous events

Tailored Retraining Program Template

1. Deficiency evaluation

2. Standard Identification

3. Tailored Retraining

1. Deficiency evaluation

1. Of the mishap aviator

2. Start with investigation finding of facts and analysis

3. Specific in nature to identify the problem

1.1 Specific in nature to identify the problem

a. HF deficiency serious?

b. What exactly deficiency in concrete terms

c. How exactly is it identified?

d. How did the HF deficiency cause the mishap to occur?

1.1 Specific in nature to identify the problem

e. From conclusion, will eliminating the HF deficiency prevent the mishap?

f. Direct demonstrable and direct cause-result logical relationship between HF hazard and the mishap?

1.1 Specific in nature to identify the problem

For example: is the pilot poor at flying go-arounds due to poor situational awareness?

1.1 Specific in nature to identify the problem

For example: is preflight planning inadequate due to poor communications skills?

1.1 Specific in nature to identify the problem

For example: is there a disregard for the SOP because of a belief that SOP only applies on checkrides, but not on line flights? If so, what section of SOP and to what consequence?

Very important Note:

Do not mis-identify HF errors that might have occurred at the same time of the mishap, but which were not the cause of the mishap, as causal.

Coincidence is not causal

1.2. Deficiency Report

Written formal report based on Mishap Investigation Report and other sources such as DFDR files

1.3. Deficiency Report

Endorsed by supervisor of flying or other appropriate authority to ensure training and ops concur on how to proceed

Step 2 of Design Template

Standard is clearly spelled out and exact without ambiguity

Is the standard in the SOP?

Is it a practice taught by instructors?

Is it a technique used on the line?

Step 2 of Design Template

If the standard is a practice or technique, it will have to be written down as a “retraining procedure.”

Step 3 of Design Template

Compare the deficiency with the standard and identify the difference

From the difference design a retraining program to link the deficient aviator with the standard

Step 3 of Design Template

Recommended recipe of action

Simple methods to remember to do the correct action at the correct time

Step 3 of Design Template

3.1. Specific ground school, simulator and flight syllabus to guide training and ops dept

3.2. Formal Written Training Program with lesson plans, resource material, additional SOP and checklists

Step 3 of Design Template

Additional scheduling, testing and academic expectations

Step 3 of Design Template

3.3. Endorsed by supervisor of flying so that there is no doubt that Tailored Retraining Program is an agreement of the highest order…

Step 3 of Design Template

3.3. …that must be completed by the mishap crew members in order to proceed with recertification if necessary and to line operations requalification.

Retraining flowing from practice and technique

Will be written directives of the training department

Will be identified as extra SOP for the crew undergoing Retraining.

Extra SOP will form a bridge

Between the SOP and what everyone else up until this time understood to be normal human factors standards

Exhibited by other line crew members

Extra SOP will form a bridge

Will serve to fill in the deficiencies in HF by the mishap crew

Extra SOP will form a bridge

For example: most crew will give a verbal take off brief from memory, with elements from the SOP

Retraining crew will use written checklist as an extra SOP to ensure all areas are covered

Extra SOP will form a bridge

Also to ensure that the rest of the crew fully understands, agrees and is prepared to do as planned

Extra SOP will form a bridge

In one example a captain said, “Brief as standard.” After TO, conditions changed, crew was confused on what to do next, did not know the intentions of the other crew member, mishap occurred in confusion.

4. Retraining is more than remedial basic skills training

Develops extra SOP that will guide the crew to comply with the SOP

4.1. Retraining is more than remedial basic skills training

Example: SOP requires Wx brief before TO, enroute and LD, but may not specifiy procedural adjustments based on specific weather.

4.1. Retraining is more than remedial basic skills training

The norm for captains is to IMC, Convective WX make a briefing comment about avoidance, windshear recovery, alternate courses, holding, anti-icing and diverts.

4.2. Retraining crew may need written convective wx SOP

A checklist to make sure that all sections of the AOM and FOM are considered for line operations

4.3. Retraining crew may need written convective wx SOP

In one example a crew had a mishap due to a microburst encounter on landing.

4.3. Retraining crew may need written convective wx SOP

Retraining may provide an extra SOP and written checklist that will guide them clear of the convective weather rather than into an encounter, to hold or divert to a clear field.

4.4. Retraining crew may need an extra written predeparture

deicing SOP

4.4. Retraining crew may need an extra written predeparture

deicing SOP

-holdover times

-engine run up times and intervals

-snow depth clutter

These items are often not found in one convenient place

4.4. Retraining crew may need an extra written predeparture

deicing SOP

Maybe this aviator needs a special checklist and an extra SOP so that every item to be reveiwed prior to a cold, snowy, windy evening departure is in one place?

4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight

tool to ensure consistency and standardization when confronted with so many other factors, such as weather and ops tempo

4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight

Maybe this particular pilot needs the briefing checklist to reset thinking when stress factors distract, such as late departures, maintenance MEL issues

4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight

Maybe this will ensure an excellent flight for this crew, despite various HF interferemce.

4.6. Retraining must be specific in nature, for example

judgment and coordination

This crew needs to exercise judgment and coordination in extra HF training

Difficult decisions practice, practice and more practice

4.6. Retraining must be specific in nature, for example

judgment and coordination

if other HF areas are not deficient, then retraining must focus solely on the areas of deficiency for improvements.

Review: Tailored Retraining

1. Specific in nature to identify HF problem

Review: Tailored Retraining

2. Formal, written training program to guide retraining crew and instructors

Review: Tailored Retraining

3. Endorsed by the supervisor of flying or other appropriate authority to guide operations and training departments

At the completion of Tailored Retraining

Retrained crew should be required to use the extra SOP and checklist for the foreseeable future

At the completion of Tailored Retraining

Intention is for the retrained crew to assimilate the extra SOP into good practice and good technique and improved communications.

After completion of Tailored Retraining

Other crew members might want a copy of the extra SOP and checklist

Consideration incorporating into new SOP?

Prevent future HF events?

Example of a HF mishap

Air Florida 90, cold snowy departure

Engine run up SOP?

Holdover in SOP?

Take off abort in SOP?

Example of a HF mishap

Might a snowy departure SOP have helped?

Might an erroneous EPR, Take off abort SOP have helped?

Example of a HF mishap

What course of retraining on these subjects have helped to prevent other HF disasters?

Conclusion: Advantage of Retraining

In lieu of regulatory admin certificate action

Formal program to directly address HF deficiencies in training

Conclusion: Advantage of Retraining

Formal program to take the recommended corrective actions of a mishap investigation and put them into training and procedures.

What is next for crew members after a mishap

investigation?

Tailored HF Retraining Program

Thank you

More case studies at

http://safetyforecast.com