Positive Human Factors Culture Presentation Haley Cornelius
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Feb 20, 2024
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Building A Positive Human Factors Culture
HALEY CORNELIUS
EMBRY-RIDDLE AERONAUTICAL UNIVERSITY
ASCI202 – INTRO TO AERONAUTICAL SCIENCE
MR. KEN CROWE
FEBRUARY 11, 2024
NTSB Report # ATL02FA175
September 23, 2002
Milton, Florida
•
Caused by corroded cable, even though annual inspection was completed 6.21 flight hours prior to accident
Total engine power loss caused by sheared cable •
Expedited students to solo flights by 15 flight hours
•
Instructor admitted the flight school did not emphasize emergency procedures
US Navy’s new Introductory Flight Screening(IFS) Program
•
Found that it did not contribute to this accident
NTSB found unauthorized fuel pump installed on aircraft
(National Transportation Safety Board, 2004).
Human Factors That Played a Role in This Accident – from “The Dirty Dozen”
•
Lack of Knowledge – 25 total flight hours, all acquired within the last 30 days
•
Pressure/Fatigue – meeting flight requirements of the IFS program or risk redesignation
•
Lack of communication – between pilot and flight instructor when loss of engine power was first realized
Pilot:
•
Complacency – missing the corroded cable during the annual inspection
•
Lack of Resources – unauthorized fuel pump installed on aircraft
•
Fatigue – possible from high operational tempo
Mechanics:
•
Pressure – pushing candidates through flight training to meet IFS program requirements
•
Failed to place an emphasis on emergency procedures and safety throughout the organization
Managers:
(Federal Aviation Administration, 2023-c).
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Understandin
g Human Factors
The entire aviation community benefits greatly from human factors research and development as it helps better understand how humans can most safely and efficiently perform their jobs and improve the tools and systems in which they interact. (Federal Aviation Administration, 2023-a).
Human factors directly cause or contribute to many aviation accidents and have been documented as a primary contributor to more than 70 percent of aircraft accidents. (Federal Aviation Administration, 2023-a).
Human Factors – “a multidisciplinary field that generates and compiles information about human capabilities and limitations, and applies it to design, development, and evaluation of equipment, systems, facilities, procedures, jobs, environments, staffing, organizations, and personnel management for safe, efficient, and effective human performance”
(Federal Aviation Administration, 2023-b).
Promoting A Positive Safety Culture
Safety Culture – “a pervasive, organization-wide attitude placing safety as the primary priority driving the way employees perform their work”
(Federal Aviation Administration, 2023-b).
Establish a formal written safety policy with an emphasis on continuous learning and safety culture
Open communication from top to bottom and streamline reporting processes
Schedule periodic safety talks/standdowns to re-establish expectations and procedures
Hold focus groups to address safety concerns within specific groups: pilots, mechanics, managers
(Britton, 2023).
Pilots
Automatic/
naturalistic decision-making training
•
Emergency procedure training
•
Tends to come with experience, but can be learned
•
Stress-management skills in high-stakes situations
•
Maintaining situational awareness
Self-evaluation using the IMSAFE checklist
Illness
– Am I sick?
Medication
– Am I taking medication that can cause drowsiness or impair judgement?
Stress
– Could I be distracted by stress in my personal/professional life?
Alcohol
– Could I still be impaired?
Fatigue
– Am I adequately rested?
Emotion
– Am I emotionally upset?
Situational Risk Management (SRM) – PAVE Checklist
P
ilot-In-Command - is the pilot prepared for this mission (experience, currency, satisfactory IMSAFE checklist)
A
ircraft – is this aircraft right for the mission and have the correct equipment? Was preflight satisfactory? Fuel quantity? Operational limitation?
En
V
ironment – Weather, Terrain, Airport, Airspace, Daytime/Nighttime
E
xternal Pressures – Passengers, timelines, personal goals, pride, ego, etc. (Federal Aviation Administration, 2023-a)
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Mechanics
Maintenance pauses for safety standdowns/safety talks
Anonymous reporting options
Safety briefings prior to high-risk operations (aircraft movements, crane evolutions, etc) using ORM
“The Dirty Dozen” mitigation training
Operational Risk Management (ORM)
Identify Hazards
Assess Hazards
Make Risk Decisions
Implement Controls
Supervis
e
(Risk Management Council, 2020
Managers
Must have a genuine commitment to safety
Open-door communication from top to bottom of chain
Employees must trust management
Establish a ”Just Culture” - individuals are not blamed for ‘honest errors,’ but are held accountable for willful violations and gross negligence (SKYbrary, 2021).
(Britton, 2023).
References
Britton, T. (2023, August 22).
5 components of safety culture in aviation SMS - with examples and resources
. 5 Components of Safety Culture in Aviation SMS - with Examples and Resources. https://aviationsafetyblog.asms-pro.com/blog/5-components-of-safety-culture-in-aviation-sms
Federal Aviation Administration. (2023-a). Aeronautical Decision-Making
. In Pilot’s handbook of aeronautical knowledge (2-1 – 2-32). U.S. Department of Transportation. https://www.faa.gov/sites/faa.gov/files/04_phak_ch2.pdf
Federal Aviation Administration. (2023-b).
Human factors in aviation maintenance
. Human Factors in Aviation Maintenance. https://www.faa.gov/about/initiatives/maintenance_hf
Federal Aviation Administration. (2023-c). Human Factors
. In Aviation maintenance technician handbook – general (pp. 14-1 – 14-34). Aviation Supplies & Academics Inc. https://www.faa.gov/regulations_policies/handbooks_manuals/aviation/amtg_handbook.pdf
National Transportation Safety Board. (2004). Aviation Investigation Final Report - ATL02FA175.
National Transportation Safety Board. https://data.ntsb.gov/Docket?ProjectID=55793
Risk Management Council. (2020).
Operational Risk Management Guide
. U.S. Department of Agriculture. https://www.fs.usda.gov/sites/default/files/2020-04/master_revised_orm_guide_02262020.pdf
SKYbrary. (2021).
Just culture
. SKYbrary Aviation Safety. https://skybrary.aero/articles/just-culture
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