Factors affecting and causing air crashes.ppt
- 1. Human Factors in Aviation P S Ganapathy Consultant (Flight Ops.) Jet Airways (India) Ltd.
- 2. 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
- 3. AVIATION INDUSTRY • Technology based • Employs 2 million people • Generates US$2,40,000 million revenue • Continuously growing • Success and Survival solely depends on SAFETY
- 4. 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
- 5. 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
- 6. 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
- 7. 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
- 8. 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
- 9. 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
- 10. 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
- 11. 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
- 12. What are the available resources? Aircraft systems Procedure Manuals and check lists Cockpit crew Flight Despatchers Cabin crew Maintenance personnel ATC
- 13. 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
- 14. 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?
- 15. 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
- 16. 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
- 17. 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.
- 18. 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
- 19. 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
- 20. 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
- 21. Focus of Human Factors Training • Aviation Physiology • Aviation Psychology • Relationship- SHEL Model
- 22. Human Factors Training Develops the INDIVIDUAL for Decision Making Effective Communication Leadership Interpersonal Skills Good Resource Management Handling of Stress Teamwork
- 23. SHEL MODEL LIVEWARE {Human}is Centre Piece Live ware - Software Live ware - Hardware Live ware - Environment Live ware - Live ware
- 24. SHEL MODEL • Live ware – Hardware Interface • Relationship between Human & Machine Work station Configuration Display and Control Design Seats
- 25. SHEL MODEL • Live ware – Software Interface • Relationship between Individual and Supporting Systems . Regulations Manuals Check Lists Standard Operating Procedures
- 26. 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.
- 27. 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
- 28. 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
- 29. MAINTENANCE CREW WEAK AREAS • 56% OMISSIONS • 30% INCORRECT INSTALLATION • 8% INCORRECT PART • 6% MISCELLANEOUS
- 30. THOUGHT PATTERNS HAZARDOUS HAZARDOUS Replace Replace ANTIDOTE ANTIDOTE ATTITUDE ATTITUDE With 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.”
- 31. 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
- 32. WHAT CAUSES ACTIVE FAILURES? N E G L I G E N C E N E G L I G E N C E 14 + 5 + 7+ 12 + 9 + 7 + 5 + 14 + 3 + 5 =81 + + E G O E G O 5 + 7+ 15 =27 + + I N C A P A C I T Y I N C A P A C I T Y 9 + 14 + 3 + 1 + 16 + 1 + 3 + 9 + 20 + 25 =101 =209 leads to leads to H U M A N E R R O R H U M A N E R R O R 8+21+13+1+14+ 5+18+18+15+!8 =131 AC C I D E N T S + AC C I D E N T S + 1+3+3+9+4+5+14+20+19 =78 = 209
- 33. 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
- 34. REACTIVE APPROACH to PROACTIVE APPROACH • Flight Operation Quality Assurance • Voluntary Incident Reporting System • Regular Safety Audit • Creating Safety Data Base and Trend Analysis
- 35. NON-PUNITIVE INCIDENT NON-PUNITIVE INCIDENT REPORTING SYSTEMS REPORTING SYSTEMS Air Safety Reports Confidential Reports Surveys
- 36. 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
- 37. 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
- 38. 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
- 39. 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.
- 40. 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
- 41. 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.
- 42. 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
- 43. Update of situational awareness Anticipate the future Refer to past experience Attend to one subject at a time
- 45. What is Inquiry ? • Information Seeking – Most Important • Visual Scan • Seeking Clarification from members • Overcoming the Sensitive EGO
- 46. 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
- 47. What is Listening? • Active Listening is key to communication • Requires active ATTENTION • Listen MORE and Speak LESS
- 48. 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
- 49. 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
- 50. 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
- 51. 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
- 52. Barriers to communication Uncommunicative attitudes Hierarchy Body language conflicting with words High workload Different cultures Different mother tongue Noise, heat, cold Stress
- 53. 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
- 54. LEADERSHIP QUALITIES • Listening • Emotional Stability • Appreciation • Decision Making • Ethics • Responsibility • Sensitivity • Humor • Image • Professional Competence
- 55. 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
- 56. PERSONALITY & ATTITUDE • Direct bearing on Decision Making • Personality is Resistant to CHANGE • Attitude is amenable to CHANGE
- 57. Followership Qualities Advocacy Assertiveness Inquiry FAA definition-“Followership is the willingness to co-operate with respect for authority and subordination of personal preferences”
- 58. 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
- 59. TEAMWORK LEADS TO SAFETY Develop R E L A T I O N S 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 S Y N E R G Y 19 +25+14+5+18+7+25 =113 leading to N I L I N C I D E N T N I L I N C I D E N T (14+19+12) (9+14+3+9+4+5+14+20) =113
- 60. REMEMBER FOR TASK ACHIEVEMENT • Tell me and I will Forget • Show me and I will Remember • INVOLVE me and I will UNDERSTAND
- 61. 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
- 62. 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
- 63. 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
- 64. 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
- 65. 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
- 66. SAFETY IS A SAFETY IS A SHARED SHARED RESPONSIBILITY RESPONSIBILITY F L I G H T S A F E T 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
- 67. 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