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Human factors in Aviation Seminar

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Anxiety never disappears in a human being in an airplane.-it merely remains ... you get the insane urge to go blasting through the skies in a pressurized metal ... – PowerPoint PPT presentation

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Title: Human factors in Aviation Seminar


1
Human factors in Aviation Seminar
  • Captain Daniel P. Mahoney
  • Master Certified Flight Instructor
  • FAA Flight Safety Counselor

2
Harold Harris, Vice President Pan American World
Airways, circa 1950
  • Attention!
  • Aircraft Designers, Operators, Airmen, Managers.
    Anxiety never disappears in a human being in an
    airplane.-it merely remains dormant when there is
    no cause to arouse it. Our challenge is to keep
    it dormant.
  • Reference Human Factors in Aviation
  • Earl L. Wiener and David C. Nagel

3
Captain Jim Sifford Piedmont Airlines To a class
of new hire pilots, circa 1978
  • We pay you not to make mistakes!

4
A Definition of Human Factors
  • Human factors (or ergonomics) may be defined as
    the technology concerned to optimize the
    relationships between people and their activities
    by the systematic application of the human
    sciences, integrated within a framework of system
    engineering.

5
Water Ditching
  • Left Over From Last Seminar…
  • Airline F/A announcement
  • Your seat cushions can be used for flotation
    and, in the event of an emergency water landing,
    please paddle to shore and take them with our
    compliments

6
The SHEL Model
  • HARDWARE
  • Buildings
  • Vehicles
  • equipment
  • SOFTWARE
  • Rules
  • Regulations
  • Laws
  • SOPs
  • LIVEWARE
  • Human Beings
  • ENVIRONMENTAL
  • Hostile physical environment?

7
The L-H Interface
  • The lines joining the system components
    represent the interfaces through which energy and
    information are exchanged.
  • LIVEWARE-HARDWARE
  • Example
  • Pilot setting the engine power over the range of
    operation
  • The engineers must create the facilities (gauges
    or glass instruments) for the pilot to operate
    the engine

8
LIVEWARE-SOFTWARE
  • Software must not be in conflict with human
    characteristics it is futile to formulate rules
    with which conformity cannot be attained and
    unwise to formulate them such that undue
    difficulty is generated.
  • Example Investigate if the rules rather than
    the violators are basically at fault.

9
LIVEWARE-ENVIRONMENTAL
  • Hostile physical environment-temperature,
    radiation, air pressure, weather etc.
  • A matter of devising ways to protect crews and
    passengers from discomfort and damage by using
    pressurized cabins, thermal insulation, and the
    like.

10
System Stability
  • Any changes within a SHEL system may have
    far-reaching repercussions. A minor equipment
    modification (change in H), for example, needs
    examination in relation to its interfaces with
    operators and maintenance personnel (
    readjust L-H) it may necessitate procedural
    changes ( readjustment of S) and hence some
    further training programs (to optimize L-S).
    Unless all such potential effects of change are
    properly pursued, it is possible for a
    comparatively small modification in a system
    component to lead to highly undesirable and
    dangerous consequences

11
Tasks that require procedures
  • Pre-flight and Checklist usage
  • Taxi-runway incursion
  • Briefing-takeoff, climb, cruise, approach, missed
    approach etc
  • Altitude Awareness
  • Automation management
  • Cockpit Resource Management
  • Single Pilot Cockpit Res.
  • Management

12
Standard Operating Procedures
  • Pilot Operating Handbook
  • Checklists
  • Airmen's information manual
  • Your own good operating practices that you follow
    by habit but are not written down

13
Food for Thought
  • Write your own SOP for your plane
  • It might include details for minimum and
    maximums for example
  • Weather briefings or personal minimums
  • Maximum flight durations
  • Night Flying etc

14
PINC
  • ACCIDENTS caused by PINC
  • Procedural Intentional Non-Compliance
  • Business and Commercial Aviation, January 2006
    Author David Huntzinger

15
Gulfstream 3 March 2001
  • According to the NTSB, the crash of the G3 at
    Aspen, Co., the crew began the approach knowing
    the landing would occur after official sunset,
    which was specifically prohibited on the approach
    plates. When the crew reached Minimum Descent
    Altitude they continued the approach without
    visual references to the runway

16
Pacific Northwest
  • A commercial pilot was flying a float-plane
    heading up a channel with rising terrain on both
    sides and a cloud deck above him. Its a VFR
    flight with passengers and cargo. Before
    committing to the channel, the pilot told himself
    he could always turn around if the situation
    deteriorated. But then the channel narrowed and
    the ceilings lowered more than he anticipated.
    Coming around a corner, he was alarmed to see a
    bridge dead ahead, its deck solidly buried in the
    cloud

17
Falcon 20
  • A German freight operation with a Falcon 20 was
    contracted to haul cargo from Poland to the US.
    The crew began the mission in Western Europe,
    flew to Poland, picked up the stuff, went to
    Iceland, refueled and then headed for Greenland
    for a night NDB/DME approach. On the outbound leg
    of the approach, they spotted the field, broke
    off and went visual. The F-20 crashed 4 miles
    from the airport killing all three pilots. The
    crew had been awake for 22 hours, on duty for 17
    and had 9.4 hours in flight in violation of
    German duty limits of 14 hours.

18
Three Elements of PINC
  • Motivation-reward if you violate the rules
  • Situational Assessment- what are my risks
  • Adverse Reaction- it is unlikely my action will
    produce any adverse reaction from my peers

19
Eliminate any One
  • The elimination of any one of the three factors
    will shut down the PINC and save the operation

20
Another F/A announcement
  • After a less than perfect landing, We ask you to
    remain seated while Captain Kangaroo bounces us
    to the terminal

21
Analyze This
  • This first accident is recent and a reflection of
    the most basic point to be made. Although HF
    studies can seem a little complicated, think of
    this old favorite.

22
Eclipse 500
  • Sept 3. Just before noon an E-500 ( new and under
    development and testing- test pilot at the
    controls- should be a good pilot, no?) was
    substantially damaged when it landed gear up at
    ABQ. The 500 was returning from a local test
    flight.
  • Pilot he was downwind for RW 3, the tower asked
    him to fly a short approach.

23
continued
  • The pilot deviated from his normal checklist
    habit pattern and he admitted he forgot to lower
    the landing gear.

24
  • PINC?
  • What procedure could he have used assuming you
    agree it was ok to help the tower by expediting?

25
GUMP?
  • Gas
  • Undercarriage
  • Mixture
  • Pumps
  • This old favorite is not completely applicable to
    a jet but will cover you none the less.

26
Young Eagles Rally
  • October 15, 2005 PA28 was destroyed due to impact
    with trees/terrain near Paine field Washington.
    VFR conditions. The aircraft was performing a
    go-around at the time of the landing event
    organizers said the aircraft was scheduled to
    land at PAE to allow the two Young Eagles to
    exchange seats.

27
Reported from witnesses and reports from the site
  • Skidded on the left side of the approach end of
    RW 16L, a second skid mark 20 feet later ( and 10
    more feet to the left) in the grass. F-2 taxiway
    sign had two posts broken.
  • Then it departed at a very low altitude and
    approximately 7000 feet down runway it topped 2-
    80 foot trees, and the wreckage came to rest 35
    feet beyond the trees, consumed by fire.

28
No conclusions at this point
  • What procedures if any could have been applied to
    help avoid this accident. This is only
    speculation and we dont presume to know the
    cause. It may never be known.
  • Do you see any ADM factors here? Lets discuss
    this.

29
Habit Patterns that should be honored
  • Could poor crosswind technique landed the pilot
    too far left of the centerline?
  • Should a go around have been initiated sooner
    rather than later. Perhaps a damaged prop
    inhibited the planes ability to climb to a safe
    altitude.
  • Do we ever discuss aborted maneuvers in GA?

30
Some ideas for us
  • Critique ourselves after every flight.
  • I need more practice on cross wind landings?
  • Brief ourselves more often. ie Land on the
    centerline in the touchdown zone
  • In the event of a GA, full power, positive pitch
    attitude, retract half of the flaps.

31
  • WAS THIS A PINC accident?

32
My Opinion
  • DONT THINK SO!

33
US AIRWAYS F/A
  • The next time you get the insane urge to go
    blasting through the skies in a pressurized metal
    tube, we hope youll think of US Airways.

34
PA-32R-301 Friday July 16, 1999
  • N9253N
  • Cause per NTSB The pilots failure to maintain
    control of the airplane during a descent over
    water at night, which was a result of spatial
    disorientation. Factors in the accident were
    haze, and the dark night.
  • Who are we talking about?

35
Some interesting Notes
  • 310 hours total time-not too shabby
  • 55 hours of night time-not too shabby
  • 36 hours in type, 9.4 at night- not too shabby
  • Flew that route 35 times in the previous 15
    months, 17 times without a CFI and 5 were at
    night. Pretty good record, hey!
  • In the past 100 days before the accident the
    pilot completed 50 of the IFR course.

36
Questions
  • In light of the notes, was the pilot too cocky?
  • Was he acting irresponsible by not having an
    instructor on board? Being rich and famous he
    could afford anything.
  • Could you see yourself in a parallel situation
    during your flying career?

37
My Opinion
  • I could and have seem myself in his situation and
    at the time.
  • Unfortunately, the pilot had similar instruction
    to myself, the difference being I took my
    instruction in 1970.
  • The same old stuff, no new stuff. GA must change
    and give pilots the tools to face new situations.

38
Only the facts mame
  • Forecast- 4-10 miles over the route
  • Dark night- I guess that means a high overcast
  • Route over land at 5500 feet, then crossing water
    34 miles west of Marthas Vineyard started
    descent at 400-800 fpm
  • Leveled off at 2200, then climbed back to 2600.
    What was his intended level off altitude?

39
What Happened Next?
  • While still in the descent, the airplane entered
    a right turn. The rate of descent and airspeed
    increased eventually exceeding 4700 fpm.
  • Examination of wreckage revealed no mechanical
    malfunction

40
NTSB
  • The pilots failure to maintain control of the
    airplane during a descent over water at night,
    which was a result of spatial disorientation.
    Factors in the accident were haze, and the dark
    night.

41
What went wrong?
  • Failure to get flight following? Would it have
    helped? Would pre-tuning 121.5 helped if he
    selected it and made a call?
  • Altitude awareness or control? First 2200, then
    2600?
  • Proper reaction to spatial disorientation? With
    50 if IFR training complete, what should he have
    known to do?

42
Procedures that might have helped hardware,softwa
re,humanware
  • Flight Following?

43
Do You Use?
  • Altitude Awareness procedures, altitude alert
    system

44
Hardware and software
  • Set desired altitude target
  • Alert system signal when 1000 feet to go
  • Set MDA or pattern altitude in the alert system
  • Set field elevation next

45
Hardware
  • USE of autopilot?

46
What do you do when you dont know which end is
up?
  • Believe your flight instruments
  • Engage your autopilot
  • What do you do when equilibrium is regained.

47
Actions
  • Divert to better weather
  • Get assistance
  • Land ASAP
  • Critique flight
  • Make a flight plan for the future

48
Future Flying
  • Examine and adopt applicable procedures developed
    through HF/ CRM studies
  • Altitude awareness, automation, unusual attitude
    practice and needle ball practice more often
  • CRM-flight following and use of radio for help
  • Consider pinch hitter program for partner

49
One more story
  • Captain- Ladies and gentlemen, this is your
    captain. The wx is good and we should have a
    smooth and uneventful flight, now sit back and
    relax, OH, MY,GOD! Then silence.
  • Ladies and Gentlemen, I am sorry if I scared you
    you earlier, the flight attendant accidentally
    spilled coffee in my lap, you should see the
    front of my pants!
  • From the back a passenger in Coach yelled,
  • Thats nothing, you see the back of mine

50
FAA Industry Training Standards
  • FITS Overview

51
Outline
  • FAA Industry Training Standards
  • Problems with Current Training
  • FITS Flight Training
  • Scenario Based Training
  • Single Pilot Resource Management
  • Learner Centered Grading
  • 5 Ps

52
FITS Goals
  • Increase GA safety
  • Reduce number of accidents
  • Improve pilot skills and decision making
  • Increase efficiency and standardization of pilot
    training
  • Reduce pilot training time
  • Reduce cost of pilot training

53
Problems with Current Training
  • Train to pass test, rather than practical
    operations in a modernized NAS.
  • Training maneuvers, rather than ADM /risk
    management.
  • Insufficient emphasis on new flight technologies
    (GPS/MFD/AP).

54
FITS Flight Training
  • Increased emphasis on decision making
  • ADM/RM/TM/AM/SA/CFIT Awareness
  • Weather decision making
  • Information management
  • Emphasis on scenario based training train the
    way you fly and fly the way you train
  • Integrated ab-initio and instrument rating

55
Scenario Based Training SBT
  • Training system that uses a highly structured
    script of real-world experiences to address
    flight training objectives in an operational
    environment.  
  • New learning techniques emphasis
  • Student role as active learners
  • Emphasis on thinking and understanding
  • Learning activities emphasize authentic, real
    world contexts for learning.
  • The object of SBT is a change in the thought
    processes, habits, and behaviors of the students.

56
Single Pilot Resource Management (SRM)
  • The art and science of managing all the
    resources
  • (both on-board the aircraft and from outside
    sources) available to a single-pilot (prior and
    during flight) to ensure that the successful
    outcome of the flight is never in doubt.
  • SRM training helps the pilot maintain
    situational awareness by managing the automation
    and associated aircraft control and navigation
    tasks. This enables the pilot to accurately
    assess and manage risk and make accurate and
    timely decisions.

57
Learner Centered Grading
  • Maneuver Grades (Tasks)
  • Explain at the completion of the scenario the
    PT will be able to describe the scenario activity
    and understand the underlying concepts,
    principles, and procedures that comprise the
    activity. Significant instructor effort will be
    required to successfully execute the maneuver
  • Practice at the completion of the scenario
    the student will be able to plan and execute the
    scenario. Coaching, instruction, and/or
    assistance from the CFI will correct deviations
    and errors identified by the CFI
  • Perform at the completion of the scenario, the
    PT will be able to perform the activity without
    assistance from the CFI. Errors and deviations
    will be identified and corrected by the PT in an
    expeditious manner. At no time will the
    successful completion of the activity be in doubt
  • Not Observed Any event not accomplished or
    required

58
Learner Centered Grading
  • Single Pilot Resource Management (SRM) Grades
  • Explain the student can verbally identify,
    describe, and understand the risks inherent in
    the flight scenario. The student will need to be
    prompted to identify risks and make decisions.
  • Practice the student is able to identify,
    understand, and apply SRM principles to the
    actual flight situation. Coaching, instruction,
    and/or assistance from the CFI will quickly
    correct minor deviations and errors identified by
    the CFI. The student will be an active decision
    maker.
  • Manage/Decide - the student can correctly gather
    the most important data available both within and
    outside the cockpit, identify possible courses of
    action, evaluate the risk inherent in each course
    of action, and make the appropriate decision.
    Instructor intervention is not required for the
    safe completion of the flight.
  • Not Observed Any event not accomplished or
    required

59
The 5 P Check
  • The Plan
  • The Plane
  • The Pilot
  • The Passengers
  • The Programming

60
Bobs Restaurant Slogan, Manteo North Carolina
  • Welcome to Bobs
  • Eat and then get the hell out
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