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Presented to: T BAA
By: Tampa FAASTeam
Date: April 17, 2013
Federal AviationAdministration
• Federal Aviation• AdministrationSafety Stand Down
2013
Building a Safety Community
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Agenda
0745 – 0845 Breakfast
0845 - 0950 Welcome and Introductions
0950 - 1000 Break
1000 – 1050 Human Factors
Dr. Karen D. Dunbar
1050 – 1100 Break
1100 – 1200 Loss of Control
Dennis H. Whitley
1200 – 1245 Lunch
1245 – 1300 Tribute To Flight Attendants
1300 – 1445 Miracle on the Hudson
Doreen Welsh
1445 – Closing remarks - Adjourn
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Welcome
• Exits• Restrooms• Emergency Evacuation• Breaks • Sponsor Acknowledgment• Other information
3
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Sponsors
Altra Medical
DJ Public Relations Inc.
ExecuJet Charter Service
Federal Aviation Administration
Federal Aviation Administration Safety Team
Hillsborough County Aviation Authority
JETEX Flight Support
4
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Sponsors
NBAA
OSI Restaurant Partners LLC
Rockwell Collins
St. Petersburg - Clearwater Int. Airport
Standard Aero
Signature Flight Support
5
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Sponsors
Landmark Aviation
Tampa Air Traffic Controllers
Tampa International Airport Fire Department
Tampa Jet Center
West Star Aviation
WINSLOW Life Raft
World Fuel
6
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Tampa FSDO Personnel• Amanda Cromie
– FSDO Manager
• Jose Figueroa– Front Line Manager
• Patrick Seggerman– Front Line Manager
• James Minary– FAASTeam Program Manager
7
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Florida FSDO Borders
• Alabama FSDO SO09
• North Florida FSDO
• SO15 & SO35 • South
Florida FSDO SO19
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
• North Florida
FSDO SO35
Florida FSDO Borders
Tampa FSDO
SO35
Orlando FSDO
SO15
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
FSDO Information– CFI and DPE Oversight– Flight Schools– Charter Companies– Film Production– Accidents & Incidents– Complaints– Repair Stations – Mechanic Schools– IA Mechanics – Special Flight Permits– Field Approvals
10
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Contact us
• http://faa.gov• Field & Regional Offices• Flight Standards District Offices (FSDO)• Select State• Select Office
11
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Wings Credits• 3 Knowledge Credits for this Stand Down
– Preregistered?• Initial roster
– Not Preregistered?• Sign in with legible faasafety.gov email
• No Account?– See a Rep today
12
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
13
1
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The Safety Stand Down
• Military Origins– Response to Safety Issue– Temporary Operations Halt– Devote time to Safety
14
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The Safety Stand Down• Human Factors
– Investigates interaction between humans and systems– Evaluates fit between user, equipment and environment– Considers capabilities and limitations – Focus on task, demands, equipment and information
• Loss of Control– Number 1 Factor in fatal accidents
• Appch. & Ldg. LOC Workgroup– Findings & Recommendations
» Technology» Human Factors
15
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Workgroup Findings
• Lack of single – pilot CRM skills• Unstabilized approaches• Flight after extended periods of not flying• Inappropriate go-around procedures• Insufficient transition training• Over reliance on automation• Flight after use of drugs• Lack of Aeronautical Decision Making Skills
16
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
FAA Information Session• Presented by:
– FAA Southern Region– Tampa Florida FAASTeam
17
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Introduction to Human Error
• Presented by:Dr. Karen D. Dunbar
FAA Safety Team
Representative
18
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Federal AviationAdministrationHuman Error
Making Sense of Accident Reports
Presented to:
FAASTeam 2013 Safety Stand Down
19
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Overview
• Error Fundamentals• System aspects of error• Application of Error Fundamentals
• Gold Seal Key Concepts
SSD 2013
20
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. Human
B. Universal
C. Inevitable
D. A bad thing
To Err is:
21
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
In so far as I am able, I agree to suspend thoughts of judgment and retribution with respect to the characters in the stories I am about to hear or relate; and to the presenter of this seminar. I will seek to understand why events occur rather than to identify and punish those
Certificate of Agreement Safety Stand Down 2013
SSD 2013
who were responsible for those occurrences. I understand that this agreement has no legal effect whatever and, in any case, applies only during this seminar unless I choose to continue with this way of thinking in the future.
22
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The 5 Ws
Who
What
When
Where
Why
23
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The 6th W
Who
What
When
Where
Why
What’s to be done about it?
24
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Four questions are easy
Who
What
When
Where
Why
What’s to be done about it?
25
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The Accident Report
Who
What
When
Where
Probable Cause
Safety Recommendation
26
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The Accident Report
Who
What
When
Where
Moose on Field
Moose proof fence
27
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Hindsight Bias
HindsightOutside
Violation
Breakdown
Lost the Bubble
Failure
Error
Bad Judgment
Incident EvolutionTime(Sidney Dekker 2006)
28
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Incident EvolutionTime
Inside
-Easy-Profitable
-Loyalty
-Prod-uctive
-Flexible
-CommonSense-Better -Skill
-Creative-Perfect
-Good Idea-Judgment-Experience
-BestOption-Quick
(Sidney Dekker 2006)
Hindsight Bias
29
SSD 2013
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Ever have one of those days?
• Take a wrong turn on a familiar route
• Set out for work when you intended to go to the store
• Lock keys in car or house
• Can’t find the keys to lock in car or house
30
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit
James Reason & Alan Hobbs (2003)
SSD 2013
31
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit
James Reason & Alan Hobbs (2003)
Blaming people for their errors is emotionally satisfying but remedially useless.
We’re still accountable for our mistakes though.
32
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Mikey’s story• Late night with interrupted sleep• Altered routine• Preoccupation with work
• How big an error?– Consequence was huge– Error was common
33
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit
SSD 2013
We all operate within systems
Sometimes without knowing it
34
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Vehicular Child Fatalities
Passenger Side Airbags vs Hyperthermia
Deaths
35
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Vehicular Child Fatalities
Passenger Side Airbags vs Hyperthermia
Deaths
36
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Vehicular Child Fatalities
Passenger Side Airbags vs Hyperthermia
Deaths
38
37
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Accident Chain of Events
38
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Accident Chain of Events
39
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Accident Chain
Unsafe Acts
Preconditions
Cultural Influences
40
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Unsafe Acts
Cultural Influences
Preconditions
Leaving Mikey in car
41
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Pre-conditions
Cultural Influences
Pax side airbag
Fatigue
Warm Weather
Preoccupation Leaving Mikey in car
Sleeping Child
42
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Cultural Influences
Child care responsibility
Work ethicPax side airbag
Fatigue
Sleeping Child
Warm Weather
Preoccupation Leaving Mikey in car
43
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Child care responsibility
Work ethicPax side airbag
Fatigue
Warm Weather
Preoccupation
Safety significant errors can occur at all levels of the system
Leaving Mikey in car
Sleeping Child
44
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The Swamp
Unsafe Acts
Preconditions
Cultural Influences
Adapted from Reason (1990)
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Adapted from Reason (1990)
Coming Soon
Bayou Junction Housing Development
Unsafe Acts
Preconditions
Cultural Influences
46
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
People
Structure/Organization
Technology
Tasks
The General Aviation System
47
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
200
01950
196
0 197
0 198
0 199
0
U.S. General AviationSource NTSB
0
10
20
30
40
50
60A
ccid
ents
/100
,000
flig
ht
ho
urs
Accidents=Approximately 7/100,000hrs
Fatal Accidents=Approximately 2/100,000hrs
48
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Human Error is Both Universal and Inevitable
It is the Downside of Having a Brain
James Reason & Alan Hobbs (2003)
SSD 2013
49
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A Simplified “Blueprint” of Mental Functioning
Input Functions
Senses
Feedback Loops
Filter
(Attention)
Conscious Workspace
Long-term memory
(Knowledge base)
Output Functions
Hands, Feet, etc.
James Reason & Alan Hobbs (2003)
50
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Conscious Workspace Long-term Memory
General Problem Solver
Limited Capacity
Contents Available
Sequential Processing
Slow and Laborious
Essential for new Tasks
Vast Collection of Programs
No Limits to Size or Duration
Unconscious
Parallel Processing
Rapid and Effortless
Handles Familiar Routines and Habits
James Reason & Alan Hobbs (2003)
Trial and Error Programming
51
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A
CBCB
A
Conscious Work Space
52
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Long-term Memory
2 + 2 = …..
knock knock “...................?”
Mary had ..................
The sky is ……..
Grass is …..
53
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Lnog-trem Meromy porgarms rley haevly on vsuisaul ifnoramiton and ptatren rcoegiontin hbaets.
Plitos are paticrculry aedpt at ptatren rcoegiontin and ulusaly taht wokrs wlel for tehm but oaccsillony taht hmaun tenendcy cuseas prelombs.
Rnunnig a falmialr porgarm in rospense to a difefernt stitauion or rnunnig a corrcet porgarm ipormprely can rsuelt in dsisater.
We are creatures of hbaet
54
SSD 2013
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Count the F’s
FINISHED FILES ARE THE RESULT
OF YEARS OF SCIENTIFIC
STUDY COMBINED WITH THE
EXPERIENCE OF MANY YEARS
55
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Count the F’s
FINISHED FILES ARE THE RESULT
OF YEARS OF SCIENTIFIC
STUDY COMBINED WITH THE
EXPERIENCE OF MANY YEARS
56
3?
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Count the F’s
FINISHED FILES ARE THE RESULT
OF YEARS OF SCIENTIFIC
STUDY COMBINED WITH THE
EXPERIENCE OF MANY YEARS
57
3 or 6?
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Choice Point needing conscious attention
New Path
Wrong Path Taken
Usual Onward Path
Skill-based Slip
Highly Routine Sequence
58
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Directly to Work
Mikey’s story
Turned left at Pereira Drive He should have turned
right at Pereira
Day Care Then work
His office's parking lot at the Department of
EducationFrom: Home
To: Work
59
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit…
SSD 2013
but they can gain a better understanding of when they’re likely to err.
60
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Error/Environment Logging
Log errors by date
Describe environment
Include health, fatigue, stress
Look for patterns
61
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Stress
Walking the line
$
6 In.
8 In.20 Ft.
62
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Stress
Walking the line
63
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Extreme Stress Makes You StupidP
erfo
rman
ce
Increasing Stress
Per
form
ance
Increasing Stress
64
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Managing the Managable
2 hour flight @ 10 gph. = 20 gal.
+ 1 hour reserve = 30 gal.
Fuel on board = 25 gal.
65
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Managing the Managable
Call for fuel & top off
Enough fuel for the return trip
Just enough time to make the luau
Launch with the fuel you haveAmple time before meeting
Must fuel before return
Consider ditching evil partner
66
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. What?
B. Why?
C. When?
D. What’s to be done about it?
The Ws that are hardest to answer are:
67
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. PCs but not MACs
B. Conscious Workspace
C. Long Term Memory
D. MACs but not PCs
Programming is an attribute of:
68
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. NTSB & FAA Investigations
B. Central Nervous System
C. Long Term Memory
D. Conscious Workspace
“Trial and Error” is an attribute of:
69
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Winners never quit ……
Quitters never….
Plan the flight & ……
You’ll never get anywhere if you don’t have a ….
When in doubt; stick to the ……
70
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Get-there-itus
Plan Continuation Bias
“The continuation of an original plan even with the availability of information that suggests that the plan should be abandoned.”
71
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
If the flight’s not conforming to the plan …..
It doesn’t pay to wait for things to get better.
Address small problems early
Before they become big ones
SSD 2013
72
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Errors are not intrinsically bad
We are “hardwired” to make errors
Bad News Good News
James Reason & Alan Hobbs (2003)
73
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The Recipe for Disaster
Human Error + Unforgiving Activity= Disaster
74
James Reason & Alan Hobbs (2003)
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
James Reason & Alan Hobbs (2003)
You cannot change the human condition,
What’s to be done about it?
but you can change the conditions in which humans work. (and play)
75
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
How many people?
76
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
or this one ….. ?
77
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
583 fatalities – 64 survivorsTenerife 27 March 1977
The Best People Tend to Make the Worst Mistakes
SSD 2013
78
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
James Reason & Alan Hobbs (2003)
Many Errors Fall into Recurrent Patterns
79
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
One More Thing
•Confirmation Bias
80
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
One More Thing
Confirmation Bias
You
Common-sense Consistent Capable CorrectCoherent Clever
Other Drivers
Ignorant IneptIdiot IncompetentImpolite Ill-mannered
Fundamental Attribution BiasJames Reason & Alan Hobbs (2003)
81
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit
• James Reason & Alan Hobbs (2003)
SSD 2013
You can’t understand why accidents happen if you assume the pilots involved were idiots.
82
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. Confirmation?
B. Hindsight?
C. Plan Continuation?
D. Fundamental Attribution?
The human biases that may negatively influence accident investigations are:
83
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. Anti-authority attitude
B. Sense of invulnerability
C. Past record of performance
D. Confirmation Bias
The best people make the worst mistakes because of their:
84
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. The Preconditions level
B. The Unsafe Acts level
C. All levels
D. Cultural Influences level
Safety-significant errors can occur at _______ of the system:
85
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. Should be avoided
B. Improve performance
C. Inhibit performance
D. Require medication
Moderate stress levels:
86
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
A. Lowest - Highest
B. Highest - Lowest
C. Lowest - Appropriate
D. Appropriate - Highest
Effective interventions should target the _______ level, but are usually most effective at the _____ level of a system.
87
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Reading List• Managing Maintenance Error
– James Reason and Alan Hobbs
• Set Phasers on Stun and The Atomic Chef– Steven Casey
• Understanding Human Error– Sidney Dekker
• Deep Survival– Laurence Gonzales
• The Limits of Expertise– Key Dismukes
• Sway– Brafman & Brafman
88
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Up next:
89
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Up next:
90
Loss of Control
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Up next:
91
Let’s take a little break
Loss of Control
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Loss of Control Panel
92
Moderated by:Dennis H. Whitley
FAA Safety Team
Lead Representative
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Loss of Control Panelists• Mr. Jack Tunstill
– CFII St. Petersburg
• Mr. Mike Windiman – CFII Plant City
93
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Fatal LOC Accidents 2001-2010
94
Man
euve
ring
App
roac
h
En
rout
e
Init.
Clim
b
Unk
now
n
Tak
e O
ff
Unc
ontr
olle
d D
esce
nt
Land
ing
Em
er.
Des
cent
Em
er.
Land
ing
Em
er.
Aft
er T
.O.
LOC Accidents 10-Year Period
0
50
100
150
200
250
300
350
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
The PAVE Checklist
• Pilot• Aircraft• enVironment• External Pressure (s)
95
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 1
96
• Pilot– Private Pilot– Total Time ……319– Time in type …. 1
• Aircraft– Jodel D-9
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 1
97
• enVironment– General Dewitt Spain, TN (M01)– Runway 16/34 225 MSL 3,800 x 75’– Left Base to Final Runway 34 – Weather (MEM – 11 nm SSE)
• VFR Few @ 7,000/10 SM• Wind Variable @ 3
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Discussion
98
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 2
99
• Pilot– Private Pilot– Total Time ……604– Time in type ….248
• Aircraft– Cirrus SR 22
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 2
100
• enVironment– Aero Plantation, NC (NC21)– Runway 6/24 634 MSL 2400 x 60’– Left Base to Final Runway 6 – Weather (EQY – 6.5 nm East)
• Wind 320@11, Gust 22
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
101
310@11, G22
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 2
102
• Parachute– Deployed, but not fully
extracted.
• Autopsy Findings– Diphenhydramine– Pseudoephedrine– Zolpidem
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Discussion
103
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 3
104
• Pilot– Private Pilot– Total Time ……975– Time in type ….44
• Aircraft– TBM 700
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 3
105
• enVironment– Cobb County Field, GA (KRYY)– Runway 9/27 1078 MSL 6311x100’– Final Approach to Runway 9 – Weather
• 5,500 BKN, 10 SM• Wind 120@6
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
106
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 3
107
• Autopsy Findings– Alfuzosin
• Prostate
– Bisoprolol *• Beta blocker
– Quinine• Arthritis
– Tramadol• For moderate to severe pain
* Known to AME
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Discussion
108
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
Dedication
Niel Armstrong 1930 - 2012
109
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Safety Stand Down 2013
April 17, 2013
Federal AviationAdministration
110
The End?• Safety never ends
– Assess & manage risk– Train to maintain – Set the example
• You are vital members of the safety community– Continue on course– Climb to greater heights– Invite others to join