Flashcards in Human Factors in Aviation Deck (26):
Pilot Competency is Based on
Training factors to ensure competency of individual pilot
Aircraft manual flight
Aircraft auto flight
Leadership and teamwork
Problem solving and decision making
Application of procedures
What is the accident rate of flying
1.2 per million flights,
zero per billion km flown
percent accidents caused by humans?
73% or 70%-80%
summarise accident trend in modern aviation
0 deaths per billion km
since 1959 rapid decline in accident rate, due to GPWS
use of statistics to develop strategy for future improvement
can identify trends
can then address possible changes in equipment, training procedures and organisation
3 components of TEM model
Hope to avoid all threats and errors
Detect errors and deal with them
Threat - External, unexpected, crew cannot predict
Error - Internal, crew's fault. Erron action or inaction
Undesired Aircraft State - crew-induced aircraft position or speed deviation, misapplication of flight controls, incorrect systems leading to reduction in margins of safety.
UAS must be crew-induced. ATC/weather things are threats.
3 types of threat - LEO
Though in some questions latent may be included inside organisational and environmental.
Can have latent, anticipated or unexpected organisational or environmental threats
Anticipated - eg weather
Unexpected - eg aircraft malfunction without warning
Latent - equipment design, mangement cutbacks, short turnaround schedules, optical illusions
Environmental - Can be planned or spontaneous
eg - ATC, airport, weather, terrain
eg - Aircraft, cabin, ground, documentation, scheduling
Explain and examples - Latent threat
Often hidden until it becomes apparent
eg - misplaced waypoint in flight software
Explain and examples - Environmental threat
Derived from the conditions that you are working in.
Generally steps can be taken to reduce these, but generally have to be dealt with in real time
eg temperature, weather, rain..
eg ATC issue such as language
eg issue with airport such as runway misaligned or bad surface, birds, bad signs
eg terrain, high ground/slope
eg similar call signs
Explain and examples - Organisational threat
To do with the company. Can normally be somehow mitigated
eg policy, communication,
eg operational pressure, delays
eg errors with charts
eg error from crew
eg maintenance error
Give ICAO definition of error
actions or inactions by the flight crew that lead to deviations from organisational or flight crew intentions or expectations
Errors must be observable.
Error can be any person, not just pilot
Primary interaction defines what kind of error.
Types of error: PAC
Procedural - Interacting with procedure
Aircraft Handling - When touching control system
Communication - Must be talking to people
examples of countermeasures for threats, errors and undesired aircraft states
Steady systematic approach to flight safety
Trap - stop it having consequences
Mitigate - stop consequences getting worse
Another list of error handling -
Error Prevention - rarely possible, needs new design
Error Reduction - minimise likelihood and magnitude
Error Detection - make apparent as fast and clearly as possible
Error Recovery - make easy to rapidly recover
Error Tolerance - minimising consequences
explain and examples of Procedural Error
not doing checklists accurately,
documentation - wrong fuel/pax etc
explain and examples - Undesired Aircraft State
flight crew-induced aircraft position or speed deviations, misapplication of flight controls, or incorrect systems configuration, associated with a reduction in margins of safety
eg wrong runway
eg bad ground handling
eg incorrect aircraft configuration
summarise relevance of shell model
Model to deal with human error
Software - rules and procedures, not just computery
Hardware - systems, displays,
Environment - Internal and external, noise, political. Situation in which L,H and S must operate
Liveware - Human, most important. Any person involved in flight. physical wellbeing, knowledge, attitides, culture, stress
Liveware (peripheral) - other humans, controllers, flight crews, engineers, maintenance personel, management and admin
This model looks at the interactions between these 5 things, with the Livewire centre of the grid
analyse interaction between the bits of SHELL
QUITE COMPLEX - will do in class
explain how interaction between individual crew members can affect flight safety
NOT COVERED YET
explain how interaction between flight crew and management can affect flight safety
NOT COVERED YET
distinguish between open and closed cultures
not covered, verify
Open - everyone knows risks, accidents, dangers. Allows mistakes to be reported without risk of sanctions. Allows others to benefit from the knowledge.
Closed - things covered up, perhaps to save face
Illustrate how safety culture is reflected by national culture
Russian people dubious of Nuclear power. Soviet government seeks to show that it is riskless by not reporting any issues. This means that no-one appreciated the dangers and no-one knew to be afraid. Conspiracy of silence, nothing learned from minor incidents,
Safety culture is a sub-set of national culture
Safety first in terms of a commercial entity
Always need to balance safety and profit
James Reason Swiss cheese model
Holes in layers of Swiss cheese are where there are gaps that prevent threats and errors creeping through.
Two types of accidents -Individual and Organisational
Individual has few defences
Organisational has many defences - harder to get through, so people actually less aware of risks.
If these holes and errors line up, then this will lead to an outcome.
Latent holes stationary
Active errors are holes that are moving around
A system is vulnerable if one error can affect a whole system
State important factors that form good safety culture
Each employee has the same attitudes, beliefs, perceptions and values that combine to form a good overall safety culture.
Starts with an Informed-Culture, ie if humans are aware of danger, they will take steps to stop it
Reports dont identify
Must be trust
Considering a typical civil aviation environment, the Safety Culture is relatively enduring, stable and resistant to change. This is true according to a question.
Distinguish between Just Culture and Non-Punitive Culture
Just culture - Members know that things can be reported without fear of punishment.
Non-punitive is no-blame