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Overcoming Human Factors by Overcoming Human Factors by Retraining: Retraining:
What is What is NextNext for Crew for Crew Members Members
After a Mishap Investigation? After a Mishap Investigation? by Captain Paul Millerby Captain Paul Miller
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Overcoming Human Factors by Overcoming Human Factors by Retraining: Retraining:
What is What is Next Next for Crew for Crew Members Members
After a Mishap Investigation? After a Mishap Investigation? by Captain Paul Millerby Captain Paul Miller
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Welcome to the 24th European Welcome to the 24th European Aviation Safety SeminarAviation Safety Seminar
Dublin, IrelandDublin, Ireland
February 29 - March 1, 2012February 29 - March 1, 2012
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partnership betweenpartnership between
European Advisory Committee, European Advisory Committee, Flight Safety Foundation Flight Safety Foundation
EurocontrolEurocontrol
European Regions Airline Association European Regions Airline Association
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Problem in a rhyme:Problem in a rhyme:What do you do,What do you do,with members of the Flight Crewwith members of the Flight Crewafter the Boards are through?after the Boards are through?You are faced with the taskYou are faced with the taskOf how to renewOf how to renewWhat has unexpectedly gone askew?What has unexpectedly gone askew?When assets are few,When assets are few,with no set course to pursue,with no set course to pursue,what do you do?what do you do?
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Retraining is a cluethat will work for you
to plan a syllabusof human factors
improoo
improvement.
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Problem:Good crew - remember that the company assigned them to the flight, as fully qualified, fully certified, fully competent, totally checked out when they began their assignment. [If they were “screwed up” as alleged, why were they assigned to operate the flight?]
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Problem:Good crew
HF particular & specific human error
Possibly loss of certification by regulator
No plan for recertification
No plan for human factors retraining
No plan tailored to this particular flight crew, who have this particular & specific HF problem
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Problem:
HF human errorPossibly loss of certification by regulatorNo plan for recertificationNo plan for human factors retrainingNo plan tailored to this particular
flightcrew, who have this particular & specific HF problem
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Problem = Need:
HF human errorPossibly loss of certification by regulatorNo plan for recertificationNo plan for human factors retrainingNo plan tailored to this particular
flightcrew, who have this particular & specific HF problem
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Need:
Plan for recertification
Plan for human factors retraining
Plan tailored to this particular flight crew, who have this particular & specific HF problem
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Need:
Plan for tailored HF retraining
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Need:
Plan for tailored HF retraining
To prepare for recertification if needed
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Why
tailored HF retraining?
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Why
tailored HF retraining?
Is it the same as recertification?
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Why
tailored HF retraining?
Is it the same as recertification?
[remember that this crew was certified at their current level of HF skill]
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Why
tailored HF retraining?Is it the same as recertification?[remember that this crew was certified at
their current level of HF skill]Most likely the Mishap Investigation
revealed “pilot error”
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Why
tailored HF retraining?Is it the same as recertification?[remember that this crew was certified at their
current level of HF skill]Most likely the Mishap Investigation revealed
“pilot error” that is, a human factors deficiency
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Why
Recertification may or may not include a human factors element
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Why?
Recertification may or may not include a human factors element
But this crew achieved certification previously but did so without achieving or maintaining competency in HF skills
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Why?
therefore, the deficiency was in HF, not in certification
Therefore, recertification alone will not address the HF deficiency.
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Why?
Even if dismissed from one company, the crew may get recertified and work for another company
Still with the HF deficiency
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Why?
If not dismissed, the crew may get recertified and work for the same company
But, …still with this particular & specific HF deficiency
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Why?
If not dismissed, the crew may get recertified and work for the same company
But, …still with this particular & specific HF deficiency … another mishap waiting to happen?
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Remember
If charges of the regulatory administrative investigation are true…
If the charges of the criminal investigatgion are true…
If the charges of the accident investigation board are true….
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Remember
Then the airman/men had gained certification once already…
Having done so with the current HF deficiencies...
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Remember
Therefore the airline policy of “dismiss and replace”
And the regulatory policy of “sanction and recertify”
May never address the human factors deficiency
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Remember
Therefore the airline policy of “dismiss and replace”
And the regulatory policy of “sanction and recertify”
May never address the human factors deficiency and is not a good solution.
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Training is Learning
We learn from our mistakes?Keep the mishap crew?Didn’t realize that they were making a
human errorEducate other flight crew to recognize
the problem, take correct action, avoid a mishap
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Accident vs Mishap
Accident
-event of chance
-event outside of human control
-uncertainty
-probability
Mishap-event of human
action/inaction-linked directly to
human behavior-preventable
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Accident vs Mishap
Accident
-event of chance
-event outside of human control
-uncertainty
-probability
Mishap-event of human
action/inaction-linked directly to
human behavior-preventable
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Accident vs Mishap
Accident
-event of chance
-event outside of human control
-uncertainty
-probability
Mishap-event of human
action/inaction-linked directly to
human behavior-preventable
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Safety Style Mishap Investigation
Finds:
-Human factors
-Human errors
Recommends Changes:
-prevent that error, that factor from being made by another crewmember again
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Safety Theory
As human errors are decreased…
…the introduction of safety hazards are decreased
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…Safety Theory
As safety hazards are decreased …
…mishaps will be decreased
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Tailored Retraining
Decrease human factors in commercial aviation by increased human factors training…
…mishaps will be decreased towards zero in commercial aviation
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Tailored Retraining derives from Safety Investigation only
-not from a Legal accident board investigation
-not from a Criminal and /or Civil Investigation
-not from an Administrative Regulatory Certification Hearing
-not from an FAA Part 709 Ride
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Tailored Retraining derives from Safety Investigation only
Seek cause of the mishap
Offer recommended corrective actions that would have prevented this mishap
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Legal Accident Board Investigations
Seek evidentiary reasons to find blame for property damage and personal injury suffered
Documents source for further litigation form compensation and punishment
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Legal Accident Board Investigations
Seldom recommend course of action for crew involved
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Admin-Regulatory Certifications
Airman Certificate
-suspend
-revoke
-reinstate
No course of action to prevent recurrence of mishaps
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FAA Part 709 Rides
Intended to weed out weak crew members and revoke certification
Not intended to retrain crew who possess a HF weakness, such as in judgment
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Human Factors Studies focus on frailties of…
-judgment
-decision making
-behavior
-communications skills
-attitude
-stress
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Human Factors Studies focus on frailties of…
-fatigue
-loss of situational awareness
-interpretation of data
-crew resource management, working together well
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Tailored Retraining focuses on how and why human frailties led to
-failure to use already established standard operating procedures (SOP)
-why, even with a very high level of compliance of SOP, some crew still do not comply at times
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Tailored Retraining focuses on how and why
-and even a few do not comply at all….
-except during check rides and training events
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Tailored Retraining is able to reach through the thought process
-For those few for whom normal training does not
-improve their compliance with SOP
-addressing HF, human error, pilot error specifically
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Tailored Retraining is not
-procedural recertification to reacquire airman certificates lost
-regular training set up to build on basic skills developed in basic training
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Linking Mishap Investigation to Tailored Retraining
-Derived from finding of facts and analysis of crew errors causing the mishap,
-Deviations from the normal procedures, practices and techniques.
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Linking Mishap Investigation to Tailored Retraining
-Conclusions, that if followed would have prevented mishap
-Deviations from the normal procedures, practices and techniques.
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Linking Mishap Investigation to Tailored Retraining
-Clearly defined steps that will prevent the mishap from recurring
-Adapts steps into custom tailored individualized HF retraining
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Linking Mishap Investigation to Tailored Retraining
-Adapting tailored retraining from non0mishap investigations is essentially the same
-incidents, other hazardous events
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Tailored Retraining Program Template
1. Deficiency evaluation
2. Standard Identification
3. Tailored Retraining
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1. Deficiency evaluation
1. Of the mishap aviator
2. Start with investigation finding of facts and analysis
3. Specific in nature to identify the problem
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1.1 Specific in nature to identify the problem
a. HF deficiency serious?
b. What exactly deficiency in concrete terms
c. How exactly is it identified?
d. How did the HF deficiency cause the mishap to occur?
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1.1 Specific in nature to identify the problem
e. From conclusion, will eliminating the HF deficiency prevent the mishap?
f. Direct demonstrable and direct cause-result logical relationship between HF hazard and the mishap?
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1.1 Specific in nature to identify the problem
For example: is the pilot poor at flying go-arounds due to poor situational awareness?
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1.1 Specific in nature to identify the problem
For example: is preflight planning inadequate due to poor communications skills?
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1.1 Specific in nature to identify the problem
For example: is there a disregard for the SOP because of a belief that SOP only applies on checkrides, but not on line flights? If so, what section of SOP and to what consequence?
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Very important Note:
Do not mis-identify HF errors that might have occurred at the same time of the mishap, but which were not the cause of the mishap, as causal.
Coincidence is not causal
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1.2. Deficiency Report
Written formal report based on Mishap Investigation Report and other sources such as DFDR files
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1.3. Deficiency Report
Endorsed by supervisor of flying or other appropriate authority to ensure training and ops concur on how to proceed
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Step 2 of Design Template
Standard is clearly spelled out and exact without ambiguity
Is the standard in the SOP?
Is it a practice taught by instructors?
Is it a technique used on the line?
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Step 2 of Design Template
If the standard is a practice or technique, it will have to be written down as a “retraining procedure.”
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Step 3 of Design Template
Compare the deficiency with the standard and identify the difference
From the difference design a retraining program to link the deficient aviator with the standard
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Step 3 of Design Template
Recommended recipe of action
Simple methods to remember to do the correct action at the correct time
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Step 3 of Design Template
3.1. Specific ground school, simulator and flight syllabus to guide training and ops dept
3.2. Formal Written Training Program with lesson plans, resource material, additional SOP and checklists
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Step 3 of Design Template
Additional scheduling, testing and academic expectations
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Step 3 of Design Template
3.3. Endorsed by supervisor of flying so that there is no doubt that Tailored Retraining Program is an agreement of the highest order…
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Step 3 of Design Template
3.3. …that must be completed by the mishap crew members in order to proceed with recertification if necessary and to line operations requalification.
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Retraining flowing from practice and technique
Will be written directives of the training department
Will be identified as extra SOP for the crew undergoing Retraining.
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Extra SOP will form a bridge
Between the SOP and what everyone else up until this time understood to be normal human factors standards
Exhibited by other line crew members
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Extra SOP will form a bridge
Will serve to fill in the deficiencies in HF by the mishap crew
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Extra SOP will form a bridge
For example: most crew will give a verbal take off brief from memory, with elements from the SOP
Retraining crew will use written checklist as an extra SOP to ensure all areas are covered
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Extra SOP will form a bridge
Also to ensure that the rest of the crew fully understands, agrees and is prepared to do as planned
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Extra SOP will form a bridge
In one example a captain said, “Brief as standard.” After TO, conditions changed, crew was confused on what to do next, did not know the intentions of the other crew member, mishap occurred in confusion.
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4. Retraining is more than remedial basic skills training
Develops extra SOP that will guide the crew to comply with the SOP
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4.1. Retraining is more than remedial basic skills training
Example: SOP requires Wx brief before TO, enroute and LD, but may not specifiy procedural adjustments based on specific weather.
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4.1. Retraining is more than remedial basic skills training
The norm for captains is to IMC, Convective WX make a briefing comment about avoidance, windshear recovery, alternate courses, holding, anti-icing and diverts.
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4.2. Retraining crew may need written convective wx SOP
A checklist to make sure that all sections of the AOM and FOM are considered for line operations
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4.3. Retraining crew may need written convective wx SOP
In one example a crew had a mishap due to a microburst encounter on landing.
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4.3. Retraining crew may need written convective wx SOP
Retraining may provide an extra SOP and written checklist that will guide them clear of the convective weather rather than into an encounter, to hold or divert to a clear field.
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4.4. Retraining crew may need an extra written predeparture
deicing SOP
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4.4. Retraining crew may need an extra written predeparture
deicing SOP
-holdover times
-engine run up times and intervals
-snow depth clutter
These items are often not found in one convenient place
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4.4. Retraining crew may need an extra written predeparture
deicing SOP
Maybe this aviator needs a special checklist and an extra SOP so that every item to be reveiwed prior to a cold, snowy, windy evening departure is in one place?
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4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight
tool to ensure consistency and standardization when confronted with so many other factors, such as weather and ops tempo
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4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight
Maybe this particular pilot needs the briefing checklist to reset thinking when stress factors distract, such as late departures, maintenance MEL issues
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4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight
Maybe this will ensure an excellent flight for this crew, despite various HF interferemce.
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4.6. Retraining must be specific in nature, for example
judgment and coordination
This crew needs to exercise judgment and coordination in extra HF training
Difficult decisions practice, practice and more practice
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4.6. Retraining must be specific in nature, for example
judgment and coordination
if other HF areas are not deficient, then retraining must focus solely on the areas of deficiency for improvements.
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Review: Tailored Retraining
1. Specific in nature to identify HF problem
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Review: Tailored Retraining
2. Formal, written training program to guide retraining crew and instructors
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Review: Tailored Retraining
3. Endorsed by the supervisor of flying or other appropriate authority to guide operations and training departments
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At the completion of Tailored Retraining
Retrained crew should be required to use the extra SOP and checklist for the foreseeable future
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At the completion of Tailored Retraining
Intention is for the retrained crew to assimilate the extra SOP into good practice and good technique and improved communications.
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After completion of Tailored Retraining
Other crew members might want a copy of the extra SOP and checklist
Consideration incorporating into new SOP?
Prevent future HF events?
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Example of a HF mishap
Air Florida 90, cold snowy departure
Engine run up SOP?
Holdover in SOP?
Take off abort in SOP?
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Example of a HF mishap
Might a snowy departure SOP have helped?
Might an erroneous EPR, Take off abort SOP have helped?
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Example of a HF mishap
What course of retraining on these subjects have helped to prevent other HF disasters?
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Conclusion: Advantage of Retraining
In lieu of regulatory admin certificate action
Formal program to directly address HF deficiencies in training
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Conclusion: Advantage of Retraining
Formal program to take the recommended corrective actions of a mishap investigation and put them into training and procedures.
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What is next for crew members after a mishap
investigation?
Tailored HF Retraining Program
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Thank you
More case studies at
http://safetyforecast.com