Categorizing Human Performance Hazards for Safety ... · [email protected] 678.777.3873 Federal Aviation Administration Categorizing Human Performance Hazards for Safety Management

Dr. Bill Johnson

Chief Scientific and Technical Advisor

Maintenance Human Factors

[email protected]

678.777.3873

Federal AviationAdministration

Categorizing Human Performance

Hazards for Safety Management

Systems

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Presentation Plan

• HF Challenges in Flt. Operations?

• SMS to the Rescue?

• PEAR : A way to consider HF Hazards

• New Thoughts and Actions

• Q&A

Top 10 Challenges - ALL

Category Name % Vote # Score

Culture/Leadership 24 524

Tech Documentation 16 356

Fatigue 11 248

Voluntary Reporting 6 134

ROI 5 120

HF Training 5 108

Pressure/Stress 4 99

Oversight & Regulations 4 95

Professionalism 3 64

Other 3 61

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www.humanfactorsinfo.com

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Presentation Plan

• HF Challenges in Flt. Operations?

• SMS to the Rescue?

• PEAR : A way to consider HF Hazards

• New Thoughts and Actions

• Q&A

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Safety Management Systems Should:

Formalize data collection

Prompt deeper root cause analysis

Identify hazards and opportunities for continuing safety

Keep a focus on human factors. (PEAR) Measure HF!

Allocate new resources to HF hazards

Show how HF interventions return the investment(Safety & Money)

Federal AviationAdministration

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Presentation Plan

• HF Challenges in Flt. Operations?

• SMS to the Rescue?

• PEAR : A way to consider HF Hazards

• New Thoughts and Actions

• Q&A

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Whatever Works for You: “The Models”

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People who perform the job

Environment for work - Organizational and physical

Actions (tasks) performed as part of the job

Resources like equipment, tools, procedures, and more

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Physiological

Health

Nutrition

Lifestyle

Alertness/fatigue

Chemical dependency

Physical

Size

Gender

Age

Strength

The five senses

Psychological

Experience

Knowledge

Training

Attitude

Emotional state

Psychosocial

Interpersonal relations

Ability to communicate

Empathy

Leadership

People — Example factors

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PEAR Can Address a Lot of Issues!

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“People” Examples

Ryanair 737-800 (September, 2005)

B-737 made three un-stabilized approaches, in thunder storms, to separate Italian airports. Final landing was saved by low-time 1st Officer.

Captain did not report that infant son had died that week.

Fatigued & Cold Medicine = Bad Day

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Environment Examples

Aloha Airlines B737-200Kahului, Hawaii, U.S.A. 1988 Upper fuselage separation

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Alaska Airlines MD-83Port Hueneme, CA, US 2000 Horizontal Stabilizer Jackscrew Failure

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Action Examples

AeroPeruLima, Peru 1996 Tape left on static ports 757-200

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Hilos B-737Grammatiko, Greece 2005 Flight crew incapacitation/Fuel starvation 737-300

A320-200 at Perpignan, France (November 2008)

• Pilots from XL Airways and Air New Zealand

• XL was returning A/C after 2 year lease

• Acceptance check ride

• Did not adhere to pre-agreed flight schedule

• Did not reserve airspace for necessary testing

• 2 of 3 AOA sensors were inop due to improper cleaning

• Crew were not trained for acceptance test missions.

BA 319 – Heathrow 2013

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Be the Passenger

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The Good News

Post Mx and Preflight Checks??

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Resource Examples

American Airlines DC-10Chicago, Illinois, U.S.A 1979 Engine fell after take-off

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Charlotte, NC: Air Midwest Flight 5481, Jan 2003

Resource Issues: technical documentation, training, personnel

resources, busy schedules, fatigue training

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Are the challenges real?

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December 07, 2011

AeroStar 350-B2

Tour of the Hover Dam

Additional Information

Following 100 Hr. Inspection

Fore/aft Servo was replaced

Post maintenance check flight flown

2 revenue tour flights flown

Flight time since maintenance was 3.5 hours

Cause

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The main rotor fore/aft servo flight control

input rod was not connected.

Bolt, washer, locking nut, and cotter pin

were missing.

Fatigue Issues

Mechanic claimed 5 hours of sleep

Inspector claimed 7 hours of sleep

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Presentation Plan

• HF Challenges in Flt. Operations?

• SMS to the Rescue?

• PEAR : A way to consider HF Hazards

• New Thoughts and Actions

• Q&A

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Compliance Philosophy ?

“…. When deviations from regulatory standards do occur, the FAA’s goal is to use the most effective means to return an individual or entity…..to full compliance and to prevent recurrence.

….FAA recognizes that some deviations arise fromfactors such as flawed procedures, simple mistakes,lack of understanding, or diminished skills. The agencybelieves that deviations of this nature can mosteffectively be corrected root cause analysis andtraining, education or other appropriateimprovements to procedures……”

FAA Order 8000.373, June, ‘15

Federal AviationAdministration

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Compliance Philosophy for Inspectors

FAA Order 8900.323.

“…the Aircraft Flight Standards approach to oversight and compliance is evolving to stress an engaged, solution-oriented, outcomes-based approach. The goal is to identify deviations from standards and correct them as effectively, quickly, and efficiently as possible….This approach will more effectively address inadvertent deviations and conserve FAA enforcement for intentional, reckless, criminal, and uncooperative behavior.

...Accordingly, AFS leaders, managers, and supervisors will support inspectors when they use critical thinking to exercise sound professional judgment and take actions in accordance with this notice.”

Federal AviationAdministration

Compliance Philosophy: Components

• Not unanimous but without blame

• Panel includes: Mgmt., Labor, and FAA

• No-Nos are: (Criminal Activity, drugs/alcohol, intentional falsification)

• See FAA AC120-66B

Aviation Safety Action Program (ASAP)

• Formalized Voluntary Reporting System

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Employee Groups Represented

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Presentation Summary

• HF Challenges in Flt. Operations?

• SMS to the Rescue?

• PEAR : A way to consider HF Hazards

• New Thoughts and Actions

• Q&A Google: “Aviation Pros Johnson”