Human Factors in Aviation

P S Ganapathy
Consultant (Flight Ops.)
Jet Airways (India) Ltd.
 Human Factors in Aviation
Background and Justification
Importance of Safety
Civil Aviation Safety Record
Causes of Accidents
What is Human Factor?
Benefits of Human Factor Training
AVIATION INDUSTRY

• Technology based

• Employs 2 million people

• Generates US$2,40,000
million revenue

• Continuously growing

• Success and Survival

solely depends on
SAFETY
 AVIATION SAFETY RECORD
Quite impressive
World wide accident rate of commercial large jet
transport aircraft of the last three decades show a
dramatic fall to 1.5 from 27 per million
departures
616 million passengers travel on US carriers in 1988
with no fatalities
1987-1996 (a decade) 600 Airlines had no accidents
at all
HULL LOSS--World Wide Jet Fleet
Accidents by Primary Cause (%)
Causes1988-97 1990-99
Human 70.5 67.5
Airplane 10.0 11.0
Weather 5.0 7.5
Maintenance 6.0 6.0
Airport/ATC 3.0 4.0
Misc 5.5 4.0
Total 100.0 100.0
HULL LOSS and /or Fatal Accidents
(By phase of Flight) (%)
Phase 1988-97 1990-99
Taxi 8 8
Take off 16 14
Climb 12 13
Cruise 9 6
Descent 2 5
Approach 17 13
Landing 36 41

5% flight time accounts for 60% of the accidents

MAJOR AREAS OF ACCIDENTS
Type 1990-97 1989-99 % Change
Push back 38 46 +21
Hit by vehicle 20 29+45
CFIT 47 36 -23
Landing 126 157+25
RTO 20 14 -30
 WHAT ARE THE LESSONS
LEARNED?

 Human Factor emphasis is paying

Dividend at a slow pace
Greater awareness has contributed to the
reduction in CFIT
Technology continues to play a major role
in accident prevention
 Safety is a cost effective tool
 NEED FOR SAFETY
ENHANCEMENT
• Human error continues to dominate as the cause of
aviation accidents (65 to 70 %)
• Since 1970 the accident rate is relatively constant
• As the number of flight departures increase, we can
anticipate an increase in the absolute number of
accidents.
• Society does not understand the accident rates and
is only concerned with the number of accidents
irrespective of any decline in the global rates
 Accident investigation reports
 The crew reacted prematurely and in a
way deviated from the laid down procedure
 Series of distractions and aggravations
in the cockpit
 The failure of the pilots to monitor
flight instruments
 Flight crews’ failure to use check list
 Lack of team work amongst crew
members
 Human factors & Flight safety
How can we prevent accidents?

Examination of Industry’s accident investigation

reports clearly establishes that different
management of available resources could have
prevented the accidents in majority of the cases
What are the available resources?
 Aircraft systems
 Procedure
 Manuals and check lists
 Cockpit crew
 Flight Despatchers
 Cabin crew
 Maintenance personnel
 ATC
 What is Management?
It is the coordinated use of the available
resources to reach a goal
 Set the goal
 Evaluate risk
 Set the priorities
 Allocate resources
 Evaluate results
 Development of Aviation Safety

1960 - 1980 Lonesome Heroes (Pilot Error)

1980- 1990 Crew Resource Management (Synergy)

1990-1999 Systemic Year (Organisation

Dimension)

WHAT IS IN STORE FROM 2000 ONWARDS?

 What is CRM?

 The effective utilization of all available

resources to achieve safe and efficient operation of
a flight
 Focus of CRM training is on the functioning of
the crew as an intact team, not simply as a
collection of technically competent individuals
 CRM aims at improving crew performance
 Human Factors

HF is the Social Movement of learning the

limit of human ability and movement and
performance, to analyse and apply the
knowledge gained to the daily operations to
in prevent Human Failure which is the
major source of accidents Aviation
 What is Human Factor ?
• Concerns with Optimizing the Relationship
between People and their Activities by
Systematic Application of Human Sciences
Integrated with System Engineering.
• It is about PEOPLE ; It is about PEOPLE in
their Working Environment and it is about
their Relationship with Machines and
Procedures.
 PROGRESS ON THE HUMAN
FACTORS FRONT
ICAO
Since 1990, holding regular global flight safety and
human factors symposium to bring in awareness.
Incorporation of the requirement of human factors
/ CRM training and in accident / incident
investigation in applicable annexes
Regulatory authorities
Inclusion of human factors training as mandatory in
the training curriculum
 PROGRESS ON THE
HUMAN FACTORS FRONT
Airlines
Imparting CRM Training to Operation personnel
emphasizing the significance of human factors for
enhanced performance
Aircraft manufacturers
Human limitations are taken into consideration in
the design of the system / layout
What is Human Factor Training ?
• Not a substitute for Technical Training
• Training directed to bring in CHANGE in
Mindset
Attitude
Culture
of Individual for enhancement of
Safety and Efficiency
 Focus of Human Factors
Training
• Aviation Physiology

• Aviation Psychology

• Relationship- SHEL Model

 Human Factors Training
Develops the INDIVIDUAL for
Decision Making
Effective Communication
Leadership
Interpersonal Skills
Good Resource Management
Handling of Stress
Teamwork
 SHEL MODEL
LIVEWARE {Human}is Centre Piece

Live ware - Software

Live ware - Hardware

Live ware - Environment

Live ware - Live ware

 SHEL MODEL
• Live ware – Hardware Interface
• Relationship between Human & Machine
Work station Configuration
Display and Control Design
Seats
 SHEL MODEL
• Live ware – Software Interface
• Relationship between Individual and
Supporting Systems
. Regulations
Manuals
Check Lists
Standard Operating Procedures
 SHEL MODEL

• Live ware – Environment Interface

• Relationship between Individual and the
Internal & External Environment
• Work area Temperature / Light / Noise /
• Physical Environment Outside the Work
area. Weather, Terrain, Infrastructure, etc.
 SHEL MODEL
• Live ware – Live ware Interface
• Relationship of individual with others in
the Work area
• Cockpit crew,Maintenance & cabin crew
• Flight Dispatcher, Ground Support
• Regulators
• Management
 FLIGHT CREW AREAS OF WEAKNESS
30% ACTIVE FAILURE
Non adherence to SOP
Law violations / Lack of Vigilance
Lack of Resource Management
20% PASSIVE FAILURE
Misunderstanding, Distraction
Complacency, Forgetfulness
45% PROFICIENCY FAILURE
Inappropriate handling of A/C
Misjudgment, Lack of Training
5% MISCELLANEOUS
 MAINTENANCE CREW WEAK
AREAS

• 56% OMISSIONS

• 30% INCORRECT INSTALLATION

• 8% INCORRECT PART

• 6% MISCELLANEOUS
 THOUGHT PATTERNS
HAZARDOUS  Replace  ANTIDOTE
ATTITUDE With
• ANTI AUTHORITY:
– “Don’t tell me.” “Follow the rules. They are usually right.”
• IMPULSIVITY:
“Do something- quickly.” “Not so fast. Think first.”
• INVULNERABILITY:
“It won’t happen to me.” “It could happen to me.”
• MACHO:
“I can do it.” “Taking chances is foolish.”
• RESIGNATION:
“What’s the use?” “I’m not helpless. I can make a difference.”
 WHAT ARE THE NEW TOOLS TO
PREVENT ACCIDENTS?
• Traditional reactive approach has to be replaced
by proactive approach to reduce human error.
• Encourage confidential non-punitive reporting
system
• Identify and eliminate adverse trends with the
effective use of DFDR to stop accidents before
they happen
• AUDIT OF THE SAFETY MATRIX
 WHAT CAUSES ACTIVE FAILURES?
N E G L I G E N C E
14 + 5 + 7+ 12 + 9 + 7 + 5 + 14 + 3 + 5 =81
+ +
E G O
5 + 7+ 15 =27
+ +
I N C A P A C I T Y
9 + 14 + 3 + 1 + 16 + 1 + 3 + 9 + 20 + 25 =101
=209
leads to
HU MAN E R R O R
8+21+13+1+14+ 5+18+18+15+!8 =131
AC C I D E N T S +
1+3+3+9+4+5+14+20+19 =78
= 209
 WHAT IS THE SOLUTION?

• INDIVIDUAL ATTITUDINAL CHANGE TO DO

THINGS IN THE CORRECT MANNER AT THE
FIRST INSTANT AS LAID DOWN IN THE
MANUAL
• SENSE OF PRIDE
• TRUE MOTIVATION AND COMMITMENT
 REACTIVE APPROACH
to
PROACTIVE APPROACH

• Flight Operation Quality Assurance

• Voluntary Incident Reporting System

• Regular Safety Audit

• Creating Safety Data Base and Trend Analysis

 NON-PUNITIVE INCIDENT
REPORTING SYSTEMS

Air Safety Reports

Confidential Reports

Surveys
 STATISTICS
(PER MILLION DEPARTURES)
Country Accident Rate
Australia 0.2
USA & Canada 0.5
Europe 0.9
Middle East 2.3
Far East 2.6
South East 3.0
South America 5.7
Africa 13.0
THIS SHOWS “CULTURE” HAS AN INFLUENCE ON
AVIATION SAFETY
 CULTURAL INFLUENCES ON
AVIATI0N SAFETY
• Attitude towards errors

• Willingness to admit mistakes

• Reporting if things are wrong

• Keeping head down and not saying anything

• Independent thinking and questioning

Error, Performance and Safety
 Errors cause aircraft accidents
 Distinguish between errors and violation
 Error: Results when action deviates from
intention; it is not intentional
Violation: Results due intentional deviation
from regulation or SOP;
Initially intentional but can become
routine
 Consequences of errors
Consequences of an error may be very different.
Therefore we must clearly differentiate between
an error and its consequences
Best example: Difference between an error
made in the simulator and the exact same error
made in the air.
Errors can be detected in a tolerant system and
corrected; behaviour is re-adopted.
 Call the colours

Red blue yellow green blue

yellow green red yellow green
red blue green red blue yellow
red blue yellow red yellow green
blue yellow blue green red
yellow blue
 Error chain reaction
With time,errors
 produce more and more negative
effects
 create conditions for new errors
 contribute to accidents.

Surrounding environment can turn a simple

error into disaster.
Error Management Prevention

 Do not exceed your skills

 Set your priorities, manage your time and
workload
 Learn from your errors; keep to the facts; do

not listen to your ego.

 Work as a team
 Use checklists, callouts, cross checks
 Adherence to SOP
Update of situational awareness
 Anticipate the future

 Refer to past experience

 Attend to one subject at a time

 Effective Communication
Needs
INQUIRY
ADVOCACY
LISTENING
CONFLICT RESOLUTION
CRITIQUE
 What is Inquiry ?
• Information Seeking – Most Important

• Visual Scan

• Seeking Clarification from members

• Overcoming the Sensitive EGO

 What is Advocacy ?
• ABILITY TO STATE WHAT YOU
KNOW OR BELIEVEIN A
FORTHRIGHT POSITION

• HOLDING TO YOUR VIEW POINT

UNTIL IT IS PROVED BY FACTS,
NOT BY AUTHORITY THAT IT IS
WRONG
 What is Listening?
• Active Listening is key to communication

• Requires active ATTENTION

• Listen MORE and Speak LESS

 CONFLICT
• Advocating own position
• Becomes destructive if the argument is over
who is RIGHT rather than what is RIGHT
• Arguments have a serious effect on the
quality of the decision
• Not necessarily bad as long as they pertain
to safety and efficiency
 How to resolve Conflict?
Have a policy of coordination that is known
and acceptable to every one
When disagreement arises, keep the discussion
only on the issues needing resolution
Bring all issues of disagreement
Acknowledge and express all feelings that are
deep enough to cloud your thinking
 Conflict Resolution
• Key to the highest level of problem solving
• Leads to deeper thinking, creative to new
ideas
• Promotes mutual respect
• Provides an opportunity to seek better
solutions
 Problem Solving Process
• Recognizes the problem
• Gathering of information of the problem
• Defining the problem based on the available
facts
• Formulates solutions
• Applies the best available solutions
• Evaluates the results
• Reformulate if necessary
 Barriers to communication

 Uncommunicative attitudes
 Hierarchy
 Body language conflicting with words
 High workload
 Different cultures
 Different mother tongue
 Noise, heat, cold
 Stress
How to improve communication?
Crew members should
 Introduce themselves
 Use professional and friendly language
 Expect and give feed back
 Report anything you feel is a threat to safety
 Captain should set the tone for cockpit-cabin
communication
 Share general expectations and address flight
specific issues
 LEADERSHIP QUALITIES
• Listening
• Emotional Stability
• Appreciation
• Decision Making
• Ethics
• Responsibility
• Sensitivity
• Humor
• Image
• Professional Competence
INTERPERSONNEL SKILLS
• Demonstrate openness to suggestions
and change
• Provide and accept feedback
• Ensure team members to freely state
opinion and participate in discussion
• Promote good relationship
• Makes the first contact a “ Magical’ ONE
 PERSONALITY & ATTITUDE

• Direct bearing on Decision Making

• Personality is Resistant to CHANGE

• Attitude is amenable to CHANGE

 Followership Qualities
 Advocacy
 Assertiveness
 Inquiry
FAA definition-“Followership is the
willingness to co-operate with respect for
authority and subordination of personal
preferences”
 Human Capital

R E A L P O W E R
(18+ 5 + 1 +12) + (16+ 15 +23+ 5+ 18) = 113
(36) + (77)
is
S Y N E R G Y
(19 + 25+14+ 5 + 18 + 7 +25 ) =113
 TEAMWORK LEADS TO SAFETY
Develop
R E L A T I O N S
18+ 5+12+1+20+9+15+14+19 = 113
to create
S Y N E R G Y
19 +25+14+5+18+7+25 =113
leading to
N I L I N C I DE NT
(14+19+12) (9+14+3+9+4+5+14+20) =113
 REMEMBER FOR TASK
ACHIEVEMENT

• Tell me and I will Forget

• Show me and I will Remember

• INVOLVE me and I will UNDERSTAND

 STRESS
• Body’s nonspecific response to demands
placed upon it, whether demands are
pleasant or unpleasant.
• Chronic (Result of long term demands by
life events both positive and negative)
• Acute (From demands placed on the body
by the task on hand)
• Fatigue,Illness and emotions are some
STRESSORS involved in flying
 Coping with stress
 Say that you feel stressed
 Recognise stress symptoms in others
 Allocate tasks
 Prioritise objectives
 Stick to documented task sharing
 Try a joke
 Never give up
 Crew decision making
47% of the fatal accidents involve crew
judgement and decision making (NTSB, 1994)

Dealing with decision is dealing with safety

Some decisions can be very bad

Making no decision can be bad also

 Some decision attitudes
Hurry up: got to get there
Invulnerability: this will not happen to me
I know what it is, it has happened to me already
I know I was right.
I have done it hundred times before
I am the boss and here is my decision
That is the way we do it here
ATC said ,“Expedite”, we must expedite
How to make better decisions
Assess the problem and manage work load
Evaluate risk and time pressure
Set objectives and priorities
Adopt response speed
Use all available resources
Refer to available procedures
Consider non-obvious implications of decisions
Manage time, buy time
 SAFETY IS A SHARED
RESPONSIBILITY

F L I GHT S AF ET Y
6+12+9+7+8+20 + 19+1+6+5+20+25 = 138

is a

J O I N T E F F O R T
10+15+9+14+20 + 5+6+6+15+18+20 = 138
ANSWER TO THE CHALLENGES OF AIR
SAFETY IN THE NEW MILLENNIUM
Attitude to be positive

Non stop vigilance

Situational awareness

Willingness to learn

Excellent communication

Resource development