FAASTeam Orlando Florida Presentation Human Factors

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FAASTeam Orlando Florida PresentationHuman
Factors
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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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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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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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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
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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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Perceptual Errors

Misjudged distance/Descent Misjudged
altitude Misjudged maneuver/procedure Clearance
not maintained Spatial disorientation/vertigo Vis
ual Illusion
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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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Routine Infractions

VFR flight into IMC (continued, performed,
encountered) Flight into adverse weather
continued IFR procedure not followed Procedures/d
irectives not followed Minimum descent altitude
not maintained Operation with known deficiency
in equipment performed
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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
ones usual behavior.
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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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Preconditions for Unsafe Acts

Substandard Conditions of Operators
Adverse Mental States Mental conditions that
affect performance
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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 Pressur
e induced by conditions/events
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Preconditions for Unsafe Acts

Substandard Conditions of Operators
Adverse Physiological States Medical/Physiologica
l conditions that preclude safe operations
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Adverse Physiological States

Spatial disorientation Impairment due to
illness Incapacitation/loss of consciousness Physi
cal impairment Hypoxia Motion sickness Illness
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Preconditions for Unsafe Acts

Substandard Conditions of Operators
Physical/Mental Limitations Situation exceeds
the capabilities of the operator.
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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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Preconditions for Unsafe Acts

Substandard Practices of Operators
Crew Resource Management Poor communication/coord
ination among personnel.
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Classification of CRM failures
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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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Preconditions for Unsafe Acts

Substandard Practices of Operators
Personal Readiness Failure to prepare mentally
or physically for duty.
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Personal Readiness

Failure to adhere to crew rest requirements Self-m
edicating Overexertion while off duty Poor
dietary practices Failure to adhere to bottle to
brief rules
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Practical Tools to Stop Worker Error

Best Practice Session at the 2009 TapRooT_at_
summit Brickey, R., Hubbartt, J., Vallee, C.
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Practical Tools to Stop Worker Error

Situation awareness Accuracy of a persons
current knowledge and understanding of task at
hand and related working conditions compared to
actual conditions at a given time
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Practical Tools to Stop Worker Error

Task preview S ummarize A nticipate F orsee E
valuate R eview
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Practical Tools to Stop Worker Error

Task preview Job site preview
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Practical Tools to Stop Worker Error

Task preview Job site preview Questioning
attitude
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Practical Tools to Stop Worker Error

Task preview Job site preview Questioning
attitude Self-checking S top T hink A ct R
eview
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Practical Tools to Stop Worker Error

Task preview Job site preview Questioning
attitude Self-checking Procedure Use and
Adherence
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Practical Tools to Stop Worker Error

Task preview Job Site preview Questioning
attitude Self-checking Procedure Use and
Adherence Effective Communication
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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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When is an error/deviation not a pilot
error/deviation?

• When it is an ATC operational error or
  operational deviation.

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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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