Flight Safety ????

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• Flight Safety ????

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2002????????
01/14 Ibertrans Aerea Embraer 120RT Zaldivar,
Spain (3/3)-(0/0)-(3/3) 01/15 Procuraduria
General De Havilland DHC-6 Chilpancingo, Mexico
(0/4)-(0/0)-(3/15) 01/16 Garuda Indonesia Boeing
737-3Q8 Klaten, Indonesia (1/0)-(0/0)-(6/54) 01/17
Petroproduccion Fairchild FH-227E El Tigre,
Colombia (5/21)-(0/0)-(5/21) 01/28 TAME Ecuador
Boeing 727-134 Cumbal Volcano, (9/83)-(0/0)-(9/83)
02/07 Volare Aviation Antonov AN-12BP Agadir,
Morocco (8/0)-(0/0)-(8/0) 02/12 Iran Air Tours
Tupolev TU-145M Khorramabad, Iran
(12/107)-(0/0)-(12/107) 02/15 Tiramavia Antonov
12BP Monrovia-Roberts (1/0)-(0/0)-(8/0) 03/15
Aerotaxi (Cuba) Antonov AN-2 Baez, Cuba
(2/14)-(0/0)-(2/14) 03/17 Djibouti Airlines Let
410 Djibouti, Africa (4/0)-(0/0)-(4/0) 04/12
Tadair Swearingen 226 Palma de Mallorca, Spain
(2/0)-(0/0)-(2/0) 04/15 Air China Boeing
767-2J6ER Pusan, South Korea (11/117)-(0/0)-(11/16
6) 04/19 SELVA Colombia Antonov AN-32A Popayan,
Colombia (0/3)-(0/0)-(3/5) 05/04 EAS Airlines
BAC One-Eleven Kanos, Nigeria (7/64)-(0/0)-(8/69)
05/07 EgyptAir Boeing 737-566 Tunis, Tunisia
(3/11)-(0/0)-(6/56) 05/07 China Northern
McDonnell Doulgas Yellow Sea Dalian, China
(9/103)-(0/0)-(9/103) 05/21 Sky Executive
Airlines Let 410UVP Calabar, Nigeria
(5/0)-(0/0)-(5/0) 05/25 Trigana Air Service De
Havilland Nabire, Indonesia (6/0)-(0/0)-(6/0)
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2002????????
05/25 China Airlines Boeing 747-209B Taiwan
Strait Penghu, (19/206)-(0/0)-(19/206) 06/01
Airquarius Aviation Hawker George, South Africa
(2/1)-(0/0)-(2/1) 06/17 Hawkins and Powers
Lockheed Walker, California U.S.A.
(3/0)-(0/0)-(3/0) 07/01 DHL Express Boeing 757
Freighter Ueberlingen, Germany (2/0)-(0/0)-(2/0)
07/04 New Gomair Boeing 707 Bangui, Central
African (16/7)-(1/1)-(17/8) 07/16 Britten-Norman
BN-2B Borneo Jungles, (2/7)-(0/1)-(2/8) 07/17
Skyline Airways DeHavilland Surkhet, Nepal
(2/2)-(0/0)-(2/2) 07/26 FedEx Boeing 727
Tallahassee, Florida, (0/0)-(3/0)-(3/0) 07/27
Ukraine Air Force Sukhoi SU-27 Lviv, Ukraine
(0/0)-(2/0)-(2/0) 07/28 Pulkovo Airlines IL-86
Moscow, Russia (14/0)-(2/0)-(16/0) 08/22 Shangri
La Air DHC-6-300 Pokhara, Nepal
(3/15)-(0/0)-(3/15) 08/29 Vostok Aviakompania
Antonov AN-28 Ayan, Russia (2/14)-(0/0)-(2/14) 08/
30 Rico Linhas Aereas Embraer 120ER Rico Branco,
Brazil (3/20)-(0/0)-(3/28) 09/14 TOTAL Linhas
Aereas ATR-42-312 Paranapanema, Brazil
(2/0)-(0/0)-(2/0) 10/01 India Military - Navy
Ilyushin IL-38/ Vasco, India (12/0)-(0/0)-(12/0)
10/23 Tretyakovo Air Ilyushin IL-62M Bishkek,
Kyrgyzstan (0/0)-(0/0)-(11/0) 10/25 Private
Charter Beech King Air A100 Eveleth, Minnesota
(2/6)-(0/0)-(2/6) 11/06 Lux Air Fokker 50
Luxembourgh (2/18)-(2/0)-(3/19)
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2002????????
11/07 Dirgantara Air Service Britten-Norman - 2A
Tarakan Indonesia (1/6)-(0/0)-(1/9) 11/08 Nepal
Airways Harbin Yunshuji Y-12 Jomsom, Nepal
(0/0)-(?)-(3/16) 11/09 Tymen Antonov AN-26
Antalya, Turkey (0/0)-(8)-(9/19) 11/11 Laoag
International Fokker F27 Manila, Philippines
(1/18)-(?)-(5/29) 11/28 Eagle Aviation Let 410
Masai Mara, Kenya (1/7)-(0/0)-(2/17) 12/03 C F F
Air Learjet 36A Astoria, OR (0/0)-(0/0)-(2/2)
12/09 Raytheon Aircraft Beechcraft 1900C
Eagleton, AR (2/1)-(0/0)-(2/1) 12/21 Transasia
Airways ATR-72-202 Penghu Islands
(2/0)-(0/0)-(2/0) 12/23 Aeromist Kharkiv Antonov
140 Baghrabad, Iran (6/38)-(0/0)-(6/38) 12/24
North Flying SA.227AC Metro III Aberdeen-Dyce
Airport, UK (0/0)-(2/0)-(2/0)
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What is the solution??
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???? Human Factors
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• Definition of Human Factors
• Human Factors discovers and applies information
  about human behavior, abilities, limitations, and
  other characteristics to the design of tools,
  machines, systems, tasks, jobs, and environments
  for productive, safe comfortable, and effective
  human use

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Display or Control Grouping
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• Load shedding
• Channelized attention
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High
Attention
Low
Low
High
Stress Level
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• Miller number

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Short term memory practice
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• ?????????????( mental models )
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  in the mental model to achieve situation
  awareness )
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  become automaticity )
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Human Factors Models
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• SHELL Model
• L Liveware
• S Software
• H Hardware
• E Environment

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SHELL Model

• Liveware
• Physical size and shape
• Physical needs
• Input characteristics
• Information processing
• Output characteristics
• Environmental tolerances

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SHELL Model

• Liveware - Liveware
• Leadership
• Crew cooperation
• Teamwork
• Personality interaction
• Staff/management relationship

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SHELL Model

• Liveware - Hardware
• Design of seats
• Design of displays
• Design of controls
• Equipment locations

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SHELL Model

• Liveware -Software
• Procedures
• Manuals
• Checklists
• Symbology
• Computer programs

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SHELL Model

• Liveware - Environment
• Adapting the human to the environment
• Helmets
• Flying suits
• Oxygen masks
• Anti-G suits
• Adapting the environment to match human
  requirements
• Pressurization
• Air-conditioning systems
• Soundproofing
• Everything affect human performance in the
  environment

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Reason Model
Defenses
Unsafe Acts
Contributing Factors
Organizational Factors
Active Failures
Latent Failures
Latent Failures
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Organizational Factors
Unsafe Supervision
Preconditions
Unsafe Acts
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??? CM-1 Male, age
41  Total Flying Hours
11,235 hrs Total Command Hours on B747-400
2,017 hrs ??? CM-2
Male, age 36 Total Flying Hours
2,442 hrs Total Command
Hours on B747-400 552 hrs  ????
CM-3 Male, age
38 Total Flying Hours
5,508 hrs Total Hours on B747-400
4,518 hrs  
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• ???05R??????,??????
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• ?????? 05L

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• PVD
• PFD

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PVD
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PVD
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Primary Flight Display
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Breakdown of a Productive System

• Latent Conditions
• PVD Procedure
• Taxi Procedure

• Latent Conditions
• PVD Training
• Assess Runway Condition

Unsafe Supervision

• Active and Latent Conditions
• Discount PVD PFD
• Loss of situational awareness

Preconditions for Unsafe Acts
Unsafe Acts

• Active Conditions
• Right turn onto 05R
• Took Off From 05R

Failed or Absent Defenses

• Accident Injury
• Crashed on a Partially Closed Runway

Adapted from Reason (1990)
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Not to Blame But to Prevent