Presented to: Orlando Florida Flying Community By: The FAASTeam - Dr. Karen D. Dunbar Date: December 7th, 2010 Federal Aviation Administration FAASTeam FAASTeam Orlando Florida Orlando Florida Presentation Presentation Human Factors Human Factors
Presented to: Orlando Florida Flying Community
By: The FAASTeam - Dr. Karen D. Dunbar
Date: December 7th, 2010
Federal AviationAdministrationFAASTeam FAASTeam
Orlando Florida Orlando Florida PresentationPresentationHuman FactorsHuman Factors
2Federal AviationAdministration
FAASTeam CFI Workshop 8
December 7, 2010
What is a Pilot Deviation?
• A pilot deviation is defined as the actions of a pilot that result in the violation of a Federal Aviation Regulation or a North American Aerospace Defense (Command Air Defense Identification Zone) tolerance. FAA Order 7210.56C.
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FAASTeam CFI Workshop 8
December 7, 2010
4Federal AviationAdministration
FAASTeam CFI Workshop 8
December 7, 2010
A Partial Listing of the Unsafe Acts of Operators
Errors
Decision Errors
“Honest mistakes,” occur when one one does not have appropriate knowledge or made a poor choice, or procedural error.
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Decision Errors
Improper inflight planning
Improper altitude/clearance
Aborted takeoff/landing decision improper
Weather evaluation inadequate
Improper refueling decisions
Improper remedial action
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FAASTeam CFI Workshop 8
December 7, 2010
A Partial Listing of the Unsafe Acts of Operators
Errors
Skill-based Errors
“Stick and rudder” and other basic flight skills that occur without significant conscious thought. Vulnerable to failures of attention, memory and/or technique.
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FAASTeam CFI Workshop 8
December 7, 2010
Skill-based Errors
Airspeed not maintained
Aircraft control inadequate
Abrupt vs. excessive vs. not maintained
Stall spin inadvertent
Altitude improper/not maintained
Inadequate visual lookout
Proper glide path not maintained
8Federal AviationAdministration
FAASTeam CFI Workshop 8
December 7, 2010
A Partial Listing of the Unsafe Acts of Operators
Errors
Perceptual Errors
Errors due to erroneous response to illusions. Occur when sensory imput is degraded.
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FAASTeam CFI Workshop 8
December 7, 2010
Perceptual Errors
Misjudged distance/Descent
Misjudged altitude
Misjudged maneuver/procedure
Clearance not maintained
Spatial disorientation/vertigo
Visual Illusion
10Federal AviationAdministration
FAASTeam CFI Workshop 8
December 7, 2010
A Partial Listing of the Unsafe Acts of Operators
Violations
Routine Infractions
“Bending” the rules tolerated by authority. Must look up the supervisory chain to identify those in authority who are not enforcing rules.
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FAASTeam CFI Workshop 8
December 7, 2010
Routine Infractions
VFR flight into IMC (continued, performed, encountered)
Flight into adverse weather continued
IFR procedure not followed
Procedures/directives not followed
Minimum descent altitude not maintained
Operation with known deficiency in equipment performed
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FAASTeam CFI Workshop 8
December 7, 2010
A Partial Listing of the Unsafe Acts of Operators
Violations
Exceptional Infractions
Isolated deviation from the rules, but not tolerated by management. Difficult to predict, since not indicative of one’s usual behavior.
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FAASTeam CFI Workshop 8
December 7, 2010
Exceptional Infractions
Low altitude flight/buzzing performed
Operation with known deficiency in equipment intentional
VFR flight into IMC intentional
Flight into adverse weather intentional
Design stress limits of aircraft exceeded
Aircraft weight and balance
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FAASTeam CFI Workshop 8
December 7, 2010
Preconditions for Unsafe Acts
Substandard Conditions of Operators
Adverse Mental States
Mental conditions that affect performance
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FAASTeam CFI Workshop 8
December 7, 2010
Adverse Mental States
Impairment – alcohol/drugs (can be OTC meds)
Fatigue – lack of sleep, flight schedule
Excessive workload
Overconfidence in personal abilities
Overconfidence in aircraft capabilities
Complacency
Diverted attention
Circadian dysrhythmia/disruption
Pressure induced by conditions/events
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FAASTeam CFI Workshop 8
December 7, 2010
Preconditions for Unsafe Acts
Substandard Conditions of Operators
Adverse Physiological States
Medical/Physiological conditions that preclude safe operations
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FAASTeam CFI Workshop 8
December 7, 2010
Adverse Physiological States
Spatial disorientation
Impairment due to illness
Incapacitation/loss of consciousness
Physical impairment
Hypoxia
Motion sickness
Illness
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FAASTeam CFI Workshop 8
December 7, 2010
Preconditions for Unsafe Acts
Substandard Conditions of Operators
Physical/Mental Limitations
Situation exceeds the capabilities of the operator.
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FAASTeam CFI Workshop 8
December 7, 2010
Physical/Mental Limitations
Lack of recent/total time
Lack of recent/Total instrument time
Visual look out not possible
Physical impairment visual deficiency
Lack of familiarity with geographical area
Lack of familiarity with aircraft
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FAASTeam CFI Workshop 8
December 7, 2010
Preconditions for Unsafe Acts
Substandard Practices of Operators
Crew Resource Management
Poor communication/coordination among personnel.
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FAASTeam CFI Workshop 8
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Classification of CRM failures
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FAASTeam CFI Workshop 8
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Crew Resource Management
Preflight planning preparation inadequate
Aircraft preflight inadequate
Crew group coordination inadequate
Poor communication/coordination within and between
aircraft, ATC, etc.
Failure of leadership
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FAASTeam CFI Workshop 8
December 7, 2010
Preconditions for Unsafe Acts
Substandard Practices of Operators
Personal Readiness
Failure to prepare mentally or physically for duty.
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FAASTeam CFI Workshop 8
December 7, 2010
Personal Readiness
Failure to adhere to crew rest requirements
Self-medicating
Overexertion while off duty
Poor dietary practices
Failure to adhere to bottle to brief rules
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FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Best Practice Session at the 2009 TapRooT@ summit
Brickey, R., Hubbartt, J., Vallee, C.
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FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Situation awareness
Accuracy of a person’s current knowledge and understanding of task at hand and related working conditions compared to actual conditions at a given time
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FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Task preview
S ummarize
A nticipate
F orsee
E valuate
R eview
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FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Task preview
Job site preview
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FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Task preview
Job site preview
Questioning attitude
30Federal AviationAdministration
FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Task preview
Job site preview
Questioning attitude
Self-checking
S top
T hink
A ct
R eview
31Federal AviationAdministration
FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Task preview
Job site preview
Questioning attitude
Self-checking
Procedure Use and Adherence
32Federal AviationAdministration
FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Task preview
Job Site preview
Questioning attitude
Self-checking
Procedure Use and Adherence
Effective Communication
33Federal AviationAdministration
FAASTeam CFI Workshop 8
December 7, 2010
Practical Tools to Stop Worker Error
Task preview
Job site preview
Questioning attitude
Self-checking
Procedure Use and Adherence
Effective communication
Phonetic alphabet
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FAASTeam CFI Workshop 8
December 7, 2010
When is an error/deviation not a pilot error/deviation?
• When it is an ATC operational error or operational deviation.
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FAASTeam CFI Workshop 8
December 7, 2010
Bottom Line
• Human error is often preventable• Adequate ability, attitude, training, skills,
experience, planning, preparation, decision making, procedure adherence, communication, and self- and situational awareness will avoid most of the errors that lead to unsafe acts by pilots.
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FAASTeam CFI Workshop 8
December 7, 2010