Human Factors in Aviation
IATA Office
Madrid, Spain, 27 February – 2 March 2012
Training Course Team
Course facilitator
Mr. Raul Sosa, Spain
hasanie@iata.org
+41 22 770 2812
Training coordinator
Mr. Edon Hasani, IATA Geneva
stephensonk@iata.org
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TCVT-05 Human Factors in Aviation
+41 22 770 2587
Product manager
Mrs. Karen Stephenson, IATA Geneva
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TCVT-05 Human Factors in Aviation
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Activities to Note
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Complete the participant list
– Ensure your details,
including email address, are
correct
Formal examination
Class photograph
Course evaluation
Course closing ceremony
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WHO are you ?
What is your preferred name in class?
WHERE do you work ?
WHAT is your job title, and
WHAT are your main responsibilities ?
WHY are you attending this course ?
Please define your expectations
5 Ws
Introduction of course participants
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Thank you
Enjoy your course
Introduction to Human Factors
Session 1
Course Objective
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The aim of this course is to demonstrate the importance
of Human Factors in aviation management
To understand and manage human factors as an
important element of your organization
Explaining the scope, applications and methods on
contemporary human factors applied to Aviation
Reposition HF to be more central in the thinking of
Aviation key decision makers
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Why Human Factors?
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Romney Duffy
John W. Saull
“Managing Risk: The Human Element”
We humans, are an integral part of modern technology
No matter how we try to spread and define the blame,
we humans are responsible for the vast majority of
errors and accidents, and most of the mistakes
We are an inseparable part of the entire technological,
social and decision making machine
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Two ways for Human Factors
Negative: human factors as a risk
Prevention of errors and unsafe behaviour
Understanding human performance limitations
Positive: the human contribution to resilience and safe
performance
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Understanding and managing human capabilities
Motivation and promotion of safety culture
Leadership
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Misconceptions about HF
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Human Factors “is a course” / training
Human Factors is CRM (Crew Resource Management)
Human Factors is only a regulatory requirement
Human Factors is a matter of system design
Human Factors does not apply to managers
Human Factors is concerned only with flying safety
Human Factors is applied Psychology
HF is and “add-on” and not integrated in day-to-day
decision making in management
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Aviation Complex World
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Aviation Complex System
Modern aviation has become a complex system
determined by:
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High demand – High production pressure
High traffic
Congested airports and airspace
High performance new technology aircraft
New technologies in ATM and Airports
Heavy regulation plus high self control
Management systems
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New Requirements for Aviation
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Complexity and size has brought new regulatory
requirements and professional practices to keep safety
at an acceptable level and increase efficiency
Current and projected environment demand new
competences on the human side
One key competence for managers and operations staff
is “Human Factors”
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Aviation as a complex system
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Aviation is defined as a complex Socio Technical System
- also as Homo-Technological System
Independent of definitions, aviation system is designed,
operated and managed by humans
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The main Human Factors problem
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Our main problem is HUMAN PERFORMANCE
Human Performance in aviation focuses on all job
related aspects at the individual, group and
organizational levels that can impact upon human
capability to successfully accomplish a wide variety
of tasks and job requirements including the
management of related changes (EUROCONTROL)
In Human Factors we consider the human
contribution to both: reliability and resilience of
complex systems
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Aviation Technology
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Technology and Humans
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Technology is expanding in aviation
New technology is more complex and increase the
demands and abilities from humans
A new proficiency profile is needed in aviation
Computers are new members of the team but not
substituting humans
In new technology environment humans interact with
information, not directly with the machines
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An expanding discipline
In spite of downturns aviation is expanding
More people want to fly and more aircraft are on
order:
2009 to 2028 29.000 new aircraft deliveries *
The domain of Human Factors discipline is also
expanding independently of Aviation
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*Boeing Current Market Outlook 2009-2028
The range of applications is increasing
The boundaries of Human Factors have been extended
Academics and research in Human Factors are increasing
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Managing Complexity
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ICAO Safety Management Systems (SMS) have the
goal of managing safety in this complex world of
Aviation
The underpinning of a SMS is the development of an
adequate SAFETY CULTURE
Safety Culture is in the filed of Human Factors as the
intersection of the Psychological and Sociological
areas
Safety Culture is a new scenario for Human Factors
intervention and improvement
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Why we should know more about
Human Factors in Aviation
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Safety: most incidents and accidents are linked to
Human Factors
Economy: efficiency and organization performance is
directly linked to Human Factor
Regulations: aviation regulations require to address
HF in different ways
Quality: quality management is based in HF
development
Best practices: in socio-technical systems like
aviation industry, our best business practices are
human centred
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Safety and HF
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Human factors have been documented as a primary
contributor to more than 80 percent of aviation
accidents
Associated with flight operations, human factors has
also become a major concern in maintenance,
ground operations at airports and air traffic
management
Modern research in accident causation models show
that accidents have also latent or deep rooted
organizational factors linked to human factors in
management
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Safety Figures 1990 - 2011
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Global Figures can Lead to
Complacency
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2005 – 2010 by Region
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Safety Concern
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Every time we have an accident, it involves some
element of human performance
Some authors say Human Factors is the last frontier
of aviation safety
Aviation systems, like airlines, air traffic control,
airports operation are complex socio technical
systems involving high human intervention in all their
life cycle
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Efficiency
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Human Factors are also closely related to system
efficiency, dependability and reliability
One of the most interesting lessons we learned in
the aviation industry in the past 15-20 years is that
ignoring human factors can also cost us a big ticket
in expenses and systems inefficiency and delays
That’s why every organization in the aviation system
is incorporating HF lessons
In operations and management
System and procedures design
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HF in System Design
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Reduced overall cost of system
development, implementation, maintenance
and operation
Increased human efficiency and productivity
through adequate design
Increased safety through better integration of
humans and improved system reliability
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Human Factors in Operations
Operations means “production”: the main process in
any organization providing any service or delivering
products (the SHARP END)*
Traditionally operations is a target field for
automation and robotization but nevertheless is the
main battle field for Human Factors
Human error has been (historically) documented as
a primary contributor to more than 70 percent of
commercial airplane hull-loss accidents (BOEING)
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The sharp end of an activity or job is the most difficult part where problems are likely to happen
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Human Factors in Management
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Repositioning Human factors as a key management skill
Identifying barriers to understanding human factors in
prevention of incidents and accidents among Key
Decision Makers in the aviation industry
Understanding the contribution of Human Factors in
successful performance
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Human Factors in Safety
Every job, to some extent, is dependant on people
When accidents do happen, they are very often a result
of the errors that people make
Careful consideration of HF can improve health and
safety by reducing the number of accidents and also the
causes of ill-health at work
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Managing human hazards and risks
Protecting personal health & safety (preventing personal
injury/ill-health).
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Low Awareness
High Awareness
Human Factors Awareness
Fuzzy
1.
Now
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Repositioning HF
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2.
Future
Well
bounde
d
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HF should be better understood and more valued by Key
Decision Makers in aviation organizations
Understanding what HF progress can do to achieve a
shift from position 1 Now (low awareness and value of
HF) to position 2. Future (improvement of human and
organization performance with respect to hazard and risk
management)
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The Answer on HF case
Human factors involves gathering information about
human abilities, limitations, and other characteristics
and applying it to tools, machines, systems, tasks, jobs,
and environment
To produce safe, comfortable, and effective human use
Aviation, human factors seeks to understand how
humans can most safely and efficiently be integrated
with technology
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To be translated into design, training, policies, or procedures to
help humans perform better
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Make HF more central on KDM thinking
and decision making
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Clarify who the KDM actually are
Explore how KDM make decisions about risks and
safety management
Identify the key HF that can do the shift
Align strategy along Quality, Safety, Human Factors
and Human Resources Management
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Group Discussion
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Who do you think makes the key decisions that take
account of and seek to influence human performance
(reducing errors and controlling unsafe behaviour) in
your organization?
What are the different types of issues that these decision
makers deal with?
How do these decision makers improve performance,
prevent error and control unsafe behaviours?
Do all managers review industry accidents regularly?
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A key question
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How could we
improve the
application of
human factors in
our organizations?
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Improving the application of HF
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Improve knowledge of HF trough training and
professional development programmes
Integrate HF to build knowledge, techniques and
requirements IMPLICITLY into standards and culture
Promote HF programmes from the regulators and
industry associations using current research and experts
from Universities and Institutes
EASA and other regulators to increase enforcement of
Human Factors as part of Safety Case and SMS, in
approval and oversight processes
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What is the Case
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Human Factors is not only to understand why
accidents happen or to improve safety
Human Factors is needed to understand humans
at work, to improve quality and efficiency in
organizations
Human Factors is fully related to Human
Performance
Human Factors is then a key element of
Management
As such, Human Factors pervades all organization
in different forms
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Technology,
equipment
1965
1970
1975
1985
Human
performance
1980
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1990
2000
?
?
?
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1995
Organisation
Changes in attributed cause types for accidents
100
90
80
70
60
40
50
30
20
10
1960
Erik Hollnagel
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SESSION REVIEW
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% Attributed cause
SESSION REVIEW
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The complex aviation system is highly dependent of
the people
Human Factors knowledge and skills are an
essential ingredient in the Aviation System
A new model of human competence is required to
handle complexity and high technology – including
Managers
Safety, as a prime requirement is going to be
supported by improved and updated human
capabilities
Human Factors in 2010 is not the same as in 1980
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Thank you
The Meaning of Human Factors
Session 2
FIRST GLOBAL SEMINAR ON HUMAN FACTORS
IN CIVIL AVIATION
Montreal, March 1990
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Seventy per cent of today's civil aviation accidents are
caused by the human factor. With a view to reducing the
number of
aircraft accidents and improving the industry’s safety record,
the International Civil Aviation Organization (ICAO) is
organizing a series of seminars, the first of which will take
place in Leningrad, USSR from 3 to 7 April, 1990.
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Introduction
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Human Factors Engineering HFE existed long before we
started talking of aviation human factors
HFE was applied to the design of early aeroplanes,
however our concern started as a result of aircraft
accidents attributed to human failures or errors
Initially we started working on aviation human factors in
the last 50 years to explain first and prevent later
accidents
This fact created an association between Human Factors
and Safety
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ICAO 1951 Accident Digest
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“It has been claimed that the possibility of accidents in
flying is inevitable by reason of the inherent conditions of
flying which necessitate, besides reliance on the
technical factor, considerable reliance on the skill,
judgement, memory, and physical and psychological
conditions of the human being.”
“These qualifications can vary between human beings,
and from day to day in the same human being, so that,
unlike the technical factor, the human factor are
extremely difficult to predict and therefore to prevent.”
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HF Practical Definition
Human Factors is
anything that affects
human performance
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HF Definitions
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The development and application of knowledge
concerning human characteristics, capabilities
and limitations to the design and operation of
aviation systems.
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IATA Airline Guide to Human Factors (1980)
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Edwards Definition
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Human Factors is concerned to optimize the
relationship between people and their activities,
by the systematic application of human
sciences, integrated within the framework of
systems engineering
Professor Elwyn Edwards (1979)
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EAAP * Definition
Human factors are defined as a multi-disciplinary
effort to compile and generate knowledge about
people at work and apply that knowledge to the
functional relationships between people, tasks,
technologies and environment in order to produce
safe and efficient human performance
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* European Association of Aviation Psychology 2008 brochure
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HFE: Human Factors / Ergonomics
Ergonomics or Human Factors is the scientific
discipline concerned with the understanding of
the interactions among humans and other
elements of a system, and the profession that
applies theoretical principles, data and methods
to design in order to optimize well being and
overall performance.
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Final Report of the IEA Future of Ergonomics Conference
January 2012
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EN 9100 (Aviation Quality Standard)
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The study of how humans behave physically and
psychologically in relation to particular environments,
products or services and the potential effect on safety.
Recognition that personnel performing tasks are affected
by physical fitness, physiological characteristics,
personality, stress, fatigue, distraction, communication
and attitude in order to ensure a safe interface between
the personnel and all other environmental elements such
as other personnel, equipment, facilities, procedures and
data
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Handbook of Aviation Human Factors *
Human factors in aviation are involved with the study of
the human's capabilities, limitations, and behaviors and
the integration of that knowledge into the systems we
design for them with the goals of enhancing safety,
performance, and the general well-being of the operators
of the systems
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*J. Koonce, University of Central Florida, USA1979
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Some Academic Definition*
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Human factors is a scientific discipline which
examines human behavior and capabilities in
order to find the best ways to design products,
equipment and systems for maximum safe,
effective, satisfying use by humans
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Human factors areas of interest:
Basic human performance - perception (auditory and
visual), cognition (action-selection, memory, decision
making), workload, skill acquisition, and knowledge
engineering
Human-computer interaction - web design, multimodal
interfaces, and usability testing
Aviation psychology - workload, situation awareness,
and interface design for air traffic management and pilots
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* California State University (Human Factors Program)
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The Scope of Human Factors Today
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Human Factors Application
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Sociology
Medicine
Physiology
Anthropology
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Ergonomics
Linguistics
Bussiness Management
Human Factors Related Fields
Applied
Psychology
HF Engineering
Neurosciences
Safety Engineering
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The Practice of HF
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Human factors practitioners come from a variety of
backgrounds, though predominantly they are
psychologists (engineering, cognitive, perceptual,
and experimental), physiologists and sociologists
Designers (industrial, interaction, and graphic),
anthropologists, technical communication scholars
and computer scientists also contribute to HF
applications
HF experts from other areas like pilots, engineers, air
traffic controllers, and other industry SME normally
contribute in multidisciplinary teams
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Human Factors Beyond Definitions
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The understanding of the properties of human
capability and human performance mostly related
with the cognition and decision making
The application of this understanding to the design
and development of systems and services
The art of ensuring successful application of human
factors knowledge to a programme or a system
(sometimes referred to as Human Factors Integration
and Human Factors Management)
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Cognition
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The way we think
The mental process of
knowing, including aspects
such as awareness,
perception, reasoning, and
judgment
That which comes to be
known, as through perception,
reasoning, or intuition;
knowledge
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Applied Cognition
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How we think as humans is as
important as what we think
The workings of our minds
have long been mysterious, but
we understand our mental
processes much better today
than 20 years ago
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Brainbows
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Brain cells: the
highest resolution
images of the brain
available today
Harvard Brain Center
developed a method
of multicolored
neurons with a
fluorescent protein
Human Factors Research
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Neurosciences and Applied Cognition research can aid
in developing better pictures of human information
processing and decision making
All high risk industries, so tied up to human performance,
should use the knowledge created through research as
new tools and methods that optimize human contribution
The industry alone probably will not sponsor the
research needed and the necessary development
Nevertheless, industry groups, regulators and maybe the
bigger stakeholders could work with the Universities and
research centres
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HF and Safety Link
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Human factors involves the study of all aspects of
the way humans relate to the world around them,
with the aim of improving operational performance,
safety, efficiency, health and wellbeing
A pioneer writer defined once that “safety in flight is
the product of human behaviour as modified by
aircraft characteristics, flight environment and
organizational influences”
Initially we started talking and writing about “the
human factors in aircraft accidents” to understand
some unexplained mishaps
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Human Technology Associations
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The simple human-machine model is of a person
interacting with a machine in some kind of
environment
The person and machine are both modeled as
information-processing devices, each with inputs,
central processing, and outputs
The complex human machine association is the
Socio Technical System like the Aviation System that
is a “complex system of systems”
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Cognitive Psychology
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Cognitive psychology attempts to understand the
nature of human thought processes
Cognitive Psychologists argue that people learn,
understand, remember, and make decisions as a
result of information they derive from current
circumstances, their existing memory, and the
consequences of their own actions
Cognitive Psychology assume that we develop such
understanding by processing this information
through a series of stages
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The Human Cognition
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One of the less known Human Factors aspect is the
cognitive process and its limitations
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Human Factors Topics
Cognition
Mental processing of information
Behaviour
People actions
Aptitudes
Skills and competences
Performance
Results of actions combined
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• Behaviour
• People actions / omissions
• System interactions
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• Cognition
• Mental Processing of Information
• Decision Making
• Aptitudes
• Skills
• Attitudes
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COMPETENCY
Mental Process
Performance
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Elements of Human Factors
Cognition
Mental Models
Situational Awareness
Decision-Making
Communication
Teamwork
Adaptability
Culture
Behaviour
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Elements of Human Factors -2Abilities
Knowledge
Skills
Attitudes
Aptitudes
Experience
Motivation
Human Error
Stress
Performance
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Scope of Human Factors is broader
than Psychology
Team work
Communication
Task sharing
Organizational issues
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HF are not related only to human mind and
Psychology
It is also related to social and interpersonal skills
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A conceptual Model of Human Factors
SHEL*
Four elements that influence performance
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*Created by Prof. Elwyn Edwards in 1972
Software
Rules, Procedures
Hardware
Monitors, machines, tools
Environment
Situation
Liveware
Individual and teams
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S
E
L
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H
L
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The relationship of human factors and
the aviation environment
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Liveware
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The critical focus of the model is the human element,
or liveware, the most critical as well as the most
flexible component in the system
The edges of this block in the original drawing are
not simple and straight, and so the other
components of the system must be carefully
matched to them
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Liveware-Liveware
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The interface between people and other people
In this interface, we are concerned with leadership,
co-operation, teamwork and personality interactions.
It includes programmes like Crew Resource
Management (CRM), the ATC equivalent – Team
Resource Management (TRM), Line Oriented Flight
Training (LOFT) etc
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Liveware-Software
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Software refers to all the laws, rules, regulations, orders,
standard operating procedures, customs and conventions
and the normal way in which things are done.
Increasingly, software also refers to the computer-based
programmes developed to operate the automated
systems
In order to achieve a safe, effective operation between
the liveware and software it is important to ensure that the
software, particularly if it concerns rules and procedures,
is capable of being implemented. Also attention needs to
be shown with phraseologies which are error prone,
confusing or too complex. More intangible are difficulties
in symbology and the conceptual design of systems.
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Liveware - Environment
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The liveware - environment interface refers to those
interactions which may be out of the direct control of
humans, namely the physical environment - temperature,
weather, etc., but within which aircraft operate.
Much of the human factor development in this area has
been concerned with designing ways in which people or
equipment can be protected, developing protective
systems for lights, noise, and radiation.
The appropriate matching of the liveware - environmental
interactions involve a wide array of disciplines, from
environmental studies, physiology, psychology through to
physics and engineering.
It is normally endorsed by Ergonomics
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Liveware-Hardware
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This is the interface of people with equipment or
machines
It is the domain of displays, workstation, the cockpit,
instruments, codes and symbols
Also the domain of human input devices like
controls, switches, keyboards, trackballs, tactile
screen and all the extended array developed to
interact the humans with the hardware in manmachine-systems
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Liveware-Hardware
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C
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L
L
S
Cultural Dimension: C-SHELL
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E
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All elements interact any change in one will
affect other elements
If all elements are not
designed to fit together,
there may be a misfit
Misfits lead to safety,
productivity, efficiency,
quality problems
SHEL in Cause Analysis
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Other HF Models
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Ergonomics Definition
Ergonomics (or human factors) is the scientific discipline
concerned with the understanding of interactions among
humans and other elements of a system, and the
profession that applies theory, principles, data and
methods to design in order to optimize human well-being
and overall system performance
International Ergonomics Association (IEA) 2000
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Maurice de Montmollin
L’Ergonomie (1986)
The use of Science to improve human work
The specific study of human work in order to improve it
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Ergonomics Contributions
Tasks
Jobs
Products
Environments
Systems
Design and evaluation of:
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To make them compatible with the needs, abilities and
limitations of people
Derived from the Greek ergon (work) and nomos (laws)
to denote the science of work, ergonomics is a systemsoriented discipline which now extends across all aspects
of human activity
IATA Training & Development Institute
Domains of Ergonomics
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Physical ergonomics
Human anatomical, anthropometric, physiological and biomechanical
characteristics
Cognitive ergonomics
Mental processes, perception, memory, reasoning, and motor response,
as they affect interactions among humans and other elements of a
system
Mental workload, decision-making, skilled performance, humancomputer interaction, human reliability, work stress and training as
these may relate to human-system design
Organizational ergonomics
Optimization of sociotechnical systems, including their organizational
structures, policies, and processes, communication, crew resource
management, work design, shift design, teamwork and quality
management
IATA Training & Development Institute
Shared Scopes
Aviation
Human
Factors
Ergonomics
IATA Training & Development Institute
The differences
Human
Factors
Engineering
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48
AVIATION
MANAGEMENT
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
A number of writers think of human factors, human
factors engineering, and ergonomics as interchangeable,
however there are differences
Definitions of human factors include a broader range of
classification categories and domains of inclusion
Definitions of human factors engineering place an
overwhelming emphasis on design as the medium to
effect change on an end-system
Definitions of ergonomics emphasize the study of
humans at work, including social aspects, as an
important characteristic
IATA Training & Development Institute
About Human Factors Knowledge
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
Aviation Human Factors is multidisciplinary in nature and
has grown by accretions rather than having been
developed systematically and deliberately
Scope, boundaries and contents are not fixed, since our
knowledge is always expanding as a result of research
We cannot keep (only) with a Human Factors Manual
written in the 80´s or 90´s
Current links and bridges with research are important
IATA Training & Development Institute
51
SESSION REVIEW
IATA Training & Development Institute
Thank you
TCVT-05 Human Factors in Aviation
Human Factors and Management
Session 3
Practical Implications of HF
TCVT-05 Human Factors in Aviation
In this Session we will discuss the practical
implications of Human Factors in the
management of organizations
2
Corporate Governance and Strategy
Occupational Health and Safety (OHS)
Safety Management
Quality Management
Human Resources Management
Line Management: Operations
Oversight and Supervision
Aviation System Planning
IATA Training & Development Institute
Human Factors and Management
We focused in the past Human Factors in Aviation
to Flight Operations and Maintenance teamwork
CRM Crew Resource Management
MRM Maintenance Resource Management
3
TCVT-05 Human Factors in Aviation
Later, following remarkable publications mainly by
Dr. James Reason (UK) we moved to the
organizational accidents and then HF in
organizations
Actually we realized that Human Factors is a key
element of general Management in aviation
IATA Training & Development Institute
Findings from review of major industry
accidents
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TCVT-05 Human Factors in Aviation
The published reviews of major accidents
provide limited information on Human Factors
management decisions
Accident reports tended to focus more on
general lessons learnt based on sharp-end
behaviour
The quite recent implementation of Safety
Management Systems in aviation will change
this, since risk management and decision
making are now clearly linked
IATA Training & Development Institute
HF and management in accidents
5
TCVT-05 Human Factors in Aviation
Some aviation accident reports contain clear HF
management recommendations or refer to HF
findings
2009 Colgan Air Accident mention several key
HF issues related to Management
Other risk industries accident reports refer more
clearly to key decision makers in organizations,
and shifting safety accountability to contractors
IATA Training & Development Institute
Integrated Management includes
Human Factors
6
TCVT-05 Human Factors in Aviation
*IATA Integrated Aviation Management System
There is clear insight in the safety reviews that even
though senior managers are involved in decision
making regarding safety (an by extension Human
Factors) decisions may be conflicted because of
other responsibilities
Integrated Management Systems like IAMS * try to
address this trough a holistic risk management
vision
IATA Training & Development Institute
7
TCVT-05 Human Factors in Aviation
Why HF is a Management duty
Do BAD APPLES
exist?
IATA Training & Development Institute
Old view on Human Factors
8
TCVT-05 Human Factors in Aviation
Dr. Sydney Dekker (2002) explains the bad
apple theory as follows:
“Complex systems would be fine, were it not for
the erratic behaviour of some unreliable people
(bad apples) in it, human errors cause accidentshumans are the dominant contributor to more
than two-thirds of them, failures come as
unpleasant surprises-they are unexpected and
do not belong to the system-failures : they are
introduced to the system only through the
inherent unreliability of people."
IATA Training & Development Institute
How to fix that?
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TCVT-05 Human Factors in Aviation
If the operational errors are attributable to poor
or lazy operational performance, then the
remedy is straightforward-identify the
individuals, take away their licenses, and put the
evil-doers behind bars
Simply put the bad apple apart of the basket
IATA Training & Development Institute
The new View
10
TCVT-05 Human Factors in Aviation
Accidents are very complex interactions of
human agents, management and organization
together with technology
Sometimes we find good people doing their best
to do a good job in an imperfect environment
Other times, not so good people were accepted
by the organization and allegedly supervised by
the management
Human performance needs to be explained in
context
IATA Training & Development Institute
Some Task for Corporate Boards
TCVT-05 Human Factors in Aviation
Human Factors Policy
Alignment of Human Factors Strategy with
Corporate Goals and Policies and OHS
Programs
Integration of HF in SMS and QMS (IAMS)
Human Performance Improvement Objectives at
manager level
11
Competence management
Selection
Training
Motivation
Supervision & Feedback
IATA Training & Development Institute
The Human Challenge
12
TCVT-05 Human Factors in Aviation
Managing organizations is about managing
people, so human factors knowledge and skills
on how to lead, motivate and supervise people
are essential in any organization
Human performance and limitations, variability,
motivation, team development, culture, training,
performance appraisal and many more are
human factors essential to managers
We are not talking here about specific Human
Resource Management
IATA Training & Development Institute
Current Management Theories
13
TCVT-05 Human Factors in Aviation
Contemporary management thought is sociotechnical, recognizing the interaction of people
and technology at workplace
Socio-technical approaches have evolved into
Human Capital and Talent Management to
emphasize the importance of people in new
organizations in order to get better
performance
IATA Training & Development Institute
Talent Management
14
TCVT-05 Human Factors in Aviation
The process of managing the supply and
capabilities of the workforce to meet the demand
for talent throughout the organization to achieve
optimal business performance and in direct
alignment with organizational goals
IATA Training & Development Institute
15
Capabilities
• Skills and
Competencies
People
• Hard skills
• Leadership
• Human Factors
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Understanding Talent Management
IATA Training & Development Institute
• Job
• Project
• Service
• Positions
Roles
What are we Talking About
IATA Training & Development Institute
High Reliability Organizations
17
TCVT-05 Human Factors in Aviation
Some high risk organizations, not only Aviation,
can be managed as High Reliability
Organizations
Military
Health
Oil and Gas Industries
Chemical
Nuclear
IATA Training & Development Institute
HRO Characteristics
Leadership
Safety and Quality Objectives
Safety Culture
Functional decentralization
Some redundancy of people and equipment
Systematic learning
18
TCVT-05 Human Factors in Aviation
Consistency and stability required for nearly
failure free operations
IATA Training & Development Institute
Safety in HRO
19
TCVT-05 Human Factors in Aviation
The HRO perspective highlight the notion
that SAFETY is something that an
organization DOES, not something that an
organization HAS
This is only possible through a high profiled
Human Factors management if we assume
that more than 80% of non-safety
occurrences are human related
IATA Training & Development Institute
Specifics of Aviation
20
TCVT-05 Human Factors in Aviation
New models in aviation are shifting from
regulatory based safety to performance based
safety
This shifting of the burden of safety from
regulators to operators really means self
regulating responsibility through the use of
Safety Management Systems
This is a new perspective for Management in
Aviation to ensure a consistent safe operations
despite the inherent complexity and risks
IATA Training & Development Institute
Aviation Management
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
The new requirement in aviation can be
expressed as PRECISSION or HIGH
RELIABILITY
This can be achieved through the proper
application of QUALITY and SAFETY
management system applying HUMAN
FACTORS knowledge and methods
IATA Training & Development Institute
22
High Skills in Practice
IATA Training & Development Institute
From Individuals to Organizations
One of the common problems with Human
Factors is:
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TCVT-05 Human Factors in Aviation
“Considerable reliance on the skill, judgement,
memory, and physical and psychological conditions of
the human being”
“These qualifications can vary between human beings,
and from day to day in the same human being, so that,
unlike the technical factor, the human factor are
extremely difficult to predict and therefore to prevent.”
IATA Training & Development Institute
HF is about improving performance at
all levels
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TCVT-05 Human Factors in Aviation
New focus of safety analysis is not only the
individuals at the “sharp end”, the operating
tasks and the active failures, but also the
situational and systemic factors
The latent failures or systemic flaws are also
created by managers decisions (or omissions)
and we can apply to them the same Human
factors science and knowledge to improve
performance at that level
IATA Training & Development Institute
Human Factors and OHS
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TCVT-05 Human Factors in Aviation
OHS is generally defined as the science of
anticipation, recognition, evaluation and control
of hazards arising in or from the workplace that
could impair the health and well-being of
workers, taking into account the possible impact
on the surrounding communities and the general
environment
OHS is often considered in management
systems but not integrated in HF Policies
Human Factors in organizations should be
related with OHS through an updated HF Policy
IATA Training & Development Institute
Safety & SMS
26
TCVT-05 Human Factors in Aviation
New model of performance based safety
SMS is valid only if suitable and competent
people is at work and customizing/operating
the system
HF should be considered at any stage of
analysis and design of change
HF are the heart of Safety Culture promotion
The case of SMS turn key solutions
IATA Training & Development Institute
Quality
27
Quality is good performance
Performance is Human Factors
ISO 9001 and Human Factors
New ISO 10018 proposal
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
The system is the
sum of behaviors
and the values of
individuals from top
to bottom
ISO 10018: THE HUMAN FACTOR
IATA Training & Development Institute
What is considered
29
TCVT-05 Human Factors in Aviation
The eight quality management principles from
ISO 9000
Human factors that can affect quality
Competence acquisition and people involvement
Specific guidance against ISO 9001 clauses
IATA Training & Development Institute
Leadership Factors
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TCVT-05 Human Factors in Aviation
The role of the leaders in the organization
Culture and values related to leadership
Change management
Knowledge management
IATA Training & Development Institute
People Involvement Factors
31
Communications
Teamwork
Networking and collaboration
Disciplines
Empowerment & responsibility
Exploration & creativity
Recognition & rewards
IATA Training & Development Institute
Competence Factors
32
Recruitment
Education & learning
Awareness
Creativity and Innovation
Competence Management
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Line Management
33
TCVT-05 Human Factors in Aviation
Line managers have to apply strategy through
plans and programs
Process design and supervision
Safety and Quality continuous oversight
Dealing directly with people and social problems
Provide direct feedback, training, and
reinforcement
Evaluating occurrences
Fixing problems
Making decisions
Culture promotion, giving example
IATA Training & Development Institute
Operations
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TCVT-05 Human Factors in Aviation
The core of Human Factors is related to the
sharp end of the organization: people working at
the line
Individual awareness of HF and consequences
of actions
Individual risk perception and assessment
Expression of habits and values: culture at work
Reporting, communicating
Teamwork
IATA Training & Development Institute
HF in Quality
35
TCVT-05 Human Factors in Aviation
Leadership Factors
People involvement factors
Competence factors
Understanding Quality and Performance
Understanding Quality management as the big
tool for change
Understanding customers
Understanding and applying requirements
Integration with general/line management
IATA Training & Development Institute
Maintenance
TCVT-05 Human Factors in Aviation
Design Stage at Engineering
Operations Stage: also the sharp end
Special awareness programs
36
The Dirty Dozen TC
US FAA Maintenance HF Programs
ICAO HF Manual
FAA HF in maintenance Package
IATA Training & Development Institute
HR Important Functions
37
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Recruitment: profiling, selection, hiring
Training
Motivation
Development of culture, climate
Supervision
Performance assessment
Career Planning
Management Team Building and Coaching
Knowledge Management
IATA Training & Development Institute
38
Human Factors in Training
Training Stages
TNA
Training Design
Kirkpatrick Evaluation
IATA Training & Development Institute
Quality Management & SMS
39
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Human factors implication
Human Resource Management implications
Alignment with Corporate Strategy
Why Quality Fails?
HF in SMS
IATA Training & Development Institute
40
New Organization Model
IATA Training & Development Institute
Recommendations
41
TCVT-05 Human Factors in Aviation
Regulators and associations to develop a more
formal communications strategy to continue to
raise awareness and understanding of Human
Factors at all levels
Integrate Human factors into wider safety
management decision making in new or already
implemented Safety Management Systems
Ensure at corporate level that Human Factors
eventually become embedded within everyday
management systems and processes
Integrate HF/Safety with OHS programs/HRM
IATA Training & Development Institute
HF application barriers
42
TCVT-05 Human Factors in Aviation
There are still barriers that exist which may
prevent or inhibit the application of Human
Factors at all corporate levels (also conflict of
policies)
As a practical exercise you can create a list of
such barriers and conflicts and propose
solutions to overcome those barriers
The key is develop industry best Human Factors
practices and work in partnership with
institutions doing research
IATA Training & Development Institute
Why managers should know HF?
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
It is an essential management skill
As part of Corporate general compliance
As related with Enterprise Risk Management
Safety accountability
IATA Training & Development Institute
Thank you
Session 4
Human Performance and
Limitations
Scope
2
TCVT-05 Human Factors in Aviation
Human Performance and Limitations is the first
HF training curriculum devised for pilot training
as part of the initial commercial pilot licence
ground school
It covers a broad range of disciplines as medical
aspects for pilots, introductory psychology and
some human interaction or teamwork issues
IATA Training & Development Institute
Capabilities and limitations of humans
This is the most classical and basic core of
contemporary human factors in aviation applied
only to pilots
ICAO Assembly Resolution in 1986 on Flight
Safety and Human Factors
Annex 1 Personnel Licences
Annex 6 Operations of Aircraft
3
TCVT-05 Human Factors in Aviation
IATA 20th. Technical Conference Istanbul 1975
Licensing requirements JAR-FCL
IATA Training & Development Institute
26th Session of ICAO Assembly 1986
4
TCVT-05 Human Factors in Aviation
70% of accidents involved Human Factors and
the problem could be aggravated by traffic
increase and extended use of automation
The ICAO Assembly directed the Council to
develop ICAO guidance material on Human
Factors
Three years later the 8th Edition of ICAO Annex
1 (Personnel Licensing) introduced the human
factors training requirement for pilots
IATA Training & Development Institute
Human Factors Training Requirements
5
TCVT-05 Human Factors in Aviation
Historically human failure has been the predominant
causal factors in aviation accidents and incidents,
however this fact was masked until 20 years ago,
and then approached very subtly
It has never been clear until then to what extent bad
human performance should or could be addressed
by training
Anyway it was clear that human factors education
and training in the aviation industry has been
deficient for years
IATA Training & Development Institute
Initial HF course for pilots ICAO
Equipment
Fitness
Psychology
Physiology
Introduction
3.50
1.75
1.75
10.50
7.00
1.75
HOURS
15%
10%
5%
5%
30%
20%
5%
PERCENTAGE
ICAO Annex 1 established in 1991 a 35 hour
course requirement for the Airline Transport Pilot
License studies with the following breakdown
Software
5.25
MODULE
Teamwork
10%
TCVT-05 Human Factors in Aviation
3.50
6
Environment
IATA Training & Development Institute
Human Factors training in JAR-FCL
7
TCVT-05 Human Factors in Aviation
In 1991 most European CAA adopted the Joint
Aviation Requirements for Flight Crew Licences,
known as JAR-FCL
This fact covered a clear pitfall of pilots training,
that was always about the aircraft flight manual
and ignored the “human” flight manual:
performances and limitations of human beings
The introduction of a 50 hours course on human
generalities, the HF issue was complemented
with Crew Resource Management training
IATA Training & Development Institute
That was a first step in preventing HF
accidents
8
TCVT-05 Human Factors in Aviation
With the new human factors training the pilots had the
basic knowledge and awareness about an important
killer and source of accidents and incidents
Pilots started understanding the real meaning of human
limitations and information about serious issues like the
sensory illusions that have provoked lot of accidents
They also learned about stress, fatigue, personality
conditioning and the real meaning of fitness to fly
However, that HF training was only for the pilots, not for
the managers or Key Decision Makers, so ignoring the
organizational human factors
IATA Training & Development Institute
Respiration and Circulation
The effects of altitude
Health and Hygiene
Diet and Digestion
Metabolism
The vision and the eye
Visual illusions
The ear: hearing and vestibular
system
High altitude environment
Sleep
The nervous system
Stress
9
TCVT-05 Human Factors in Aviation
Human information processing
Situational awareness
Communication
Decision making
Behaviour and Motivation
Personality
Leadership/Followership
Error and Error Chain
Automation
Learning and Learning Styles
CRM and MCC
Curricula Content JAR-FCL 1991
IATA Training & Development Institute
JAR-FCL HF course length
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TCVT-05 Human Factors in Aviation
Human Performance and Limitations: 50 hours
theoretical training out of a total of 750 hours
total training for ATPL (7%)
Multi Crew Cooperation (MCC) Course 25 hours
total time (5 hours approx. Human Factors)
Crew Resource Management (CRM) Training 5
to 10 hours a year in several versions (Initial,
Recurrent, Command, Type Rating)
IATA Training & Development Institute
Human Performance and Limitations in
practice
11
TCVT-05 Human Factors in Aviation
Airbus A-320
(1993)
TCVT-05 Human Factors in Aviation
An important part of human characteristics and
limitations have been addressed by aircraft
manufacturers in the design of aircraft and
systems integration
This could be referred as the Ergonomics of the
flight deck, and has been particularly interesting
in the last two decades when “glass cockpit” and
highly automated aircraft appeared
IATA Training & Development Institute
12
60 years of progress
Lockheed Electra 10
(1933)
IATA Training & Development Institute
Human Performance and Limitations in
Accidents
13
TCVT-05 Human Factors in Aviation
There is not a standard or even a taxonomy for
human factors in aircraft accident reporting
As a result is not easy to get HF data from accidents
reports
Apart from issues cited like “poor judgement”; “pilot
error”, “poor decision making”; situational
awareness” and thinks like that the most basic HF in
accidents are:
Fatigue
Visual /sensory illusions
IATA Training & Development Institute
Main physical human characteristics
Human variability and anthropomorphic issues
Body strength
Human adaptability/limitations
14
TCVT-05 Human Factors in Aviation
CREW
SELECTION
Environmental: Temperature, humidity, noise, lighting
Pressure
Acceleration forces and their effects
AIRCRAFT
DESIGN
IATA Training & Development Institute
Human limitations and accidents
The two main classes of commercial aircraft
accidents are:
CONTROLLED FLIGHT INTO TERRAIN – CFIT
LOSS OF CONTROL IN THE AIR – LOC
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TCVT-05 Human Factors in Aviation
Although is never a single cause accident, both
kind of mishaps are influenced by basic human
performance limitations related with the
vestibular system and the resulting spatial
disorientation
IATA Training & Development Institute
Spatial Disorientation
Spatial disorientation (SD) is among the most common
factors contributing to aviation accidents and incidents,
but its true prevalence is difficult to establish
What is spatial disorientation?
16
TCVT-05 Human Factors in Aviation
Spatial disorientation to a pilot means simply the inability to tell
which way is “up”
Used when the pilot fails to sense correctly the position, motion
or attitude of his aircraft or of himself within the fixed coordinate
system provided by the surface of the Earth and the gravitational
vertical
Also errors in perception by the pilot of his position, motion or
attitude with respect to his aircraft, or of his own aircraft relative
to other aircraft, may also be embraced within a broader
definition of spatial disorientation in flight
IATA Training & Development Institute
How the humans get space-oriented
17
TCVT-05 Human Factors in Aviation
Humans sense position and motion in threedimensional space through the interaction of a
variety of body sensors including muscles, tendons,
joints, vision, touch, pressure, hearing, and the
vestibular system
Feedback from these systems is interpreted by the
brain as position and motion data and provides
SPATIAL ORIENTATION or position sense
The vestibular system located in the inner ear
enables a person to determine body orientation,
sense the direction and speed of movement and
maintain balance
IATA Training & Development Institute
What could go wrong with balance
18
TCVT-05 Human Factors in Aviation
When there is limited visual input, as is common in
many flight situations, the vestibular sense becomes
important for gathering information
However, the vestibular system is designed to work
on the ground in a “1G” environment and therefore
during some flight maneuvers can provide flight
crews with erroneous or disorienting information
Remember also that standard airline flight
simulators cannot produce more than 1G and
therefore are not able to reproduce spatial
disorientation to pilots
IATA Training & Development Institute
Human body evolved walking, not flying
19
TCVT-05 Human Factors in Aviation
The vestibular system is believed to play a role
in the onset of motion sickness and simulator
sickness
Other sensations and illusions are generated
during turns and maneuvers involving linear or
angular acceleration
IATA Training & Development Institute
Illusions in Movement
20
TCVT-05 Human Factors in Aviation
Such illusions are so compelling they can be
extremely dangerous (several accidents still
occurring)
Reacting to them in the wrong way or by reflex
can lead to disaster.
Special knowledge, techniques and training is
needed to prevent spatial disorientation in flight
IATA Training & Development Institute
IATA Training & Development Institute
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
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23
Spatial disorientation
In general, vestibular
illusions occur under
conditions in which a
pilot is unable to see
a clear horizontal
reference
The risk is increased
at night, in clouds or
in bad weather
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
Vestibular related most common
illusions
Somatogyral illusions, caused by angular
accelerations sensed by the semicircular canals:
Graveyard spin and spiral
Coriolis illusion
24
TCVT-05 Human Factors in Aviation
Somatogravic illusions or pitch-up illusions
caused by linear accelerations
Inversion illusion
Head up illusion
Head down illusion
IATA Training & Development Institute
Operational consequences
25
TCVT-05 Human Factors in Aviation
Vestibular illusions are most likely to contribute to accidents during a
go-around
This is because when flaps and gear are retracted and full thrust is
applied at landing weight, the aircraft accelerates quite quickly,
If the pitch-up illusion is experienced, pilots can be led to believe
that they are actually at a much greater angle than they really are
and will feel as if the aircraft might stall.
The instinctive human reaction to this is to push the nose down,
ignoring indications from instruments
By the time they realize what has happened at a low altitude, it may
be too late to recover
Similarly, the nose-low illusion due to deceleration just after
touchdown can cause the pilot to pull up, resulting in excessive pitch
and a tail strike.
IATA Training & Development Institute
Some related accidents
26
TCVT-05 Human Factors in Aviation
25% Air Force and 40% General Aviation
accidents in the US are related to spatial
disorientation
No special published statistic for airlines on SD
Gulf Air Airbus A-320 August 2000
Flash Airlines B737 January 2004
Armavia Airbus A-320 May 2006
Kenya Airways B737 May 2007
Atlasjet MD-83 November 2007
IATA Training & Development Institute
The Bárány chair
27
TCVT-05 Human Factors in Aviation
Inexpensive devices are needed
IATA Training & Development Institute
Spatial disorientation (SD)
28
TCVT-05 Human Factors in Aviation
SD is an example of HF hazard to pilots
It is a function of the inherent operating
limitations of the normal human orientation
systems in the three dimensional, complex
motion environment of flight
It can happen to any normal pilot at any time
IATA Training & Development Institute
SD in flight
29
There are many different
illusions and
disorientating
phenomena that pilots
may experience,
depending on the nature
of their operations and
the phase of flight
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
SD requires awareness and training
30
TCVT-05 Human Factors in Aviation
There are many steps that can be taken by pilots
to minimize their risk of experiencing SD on a
given flight, many of which involve pre-flight
planning and adequate preparation (Education
and Training)
Being aware of the risk of SD is one of the key
elements in preventing a SD accident.
IATA Training & Development Institute
Main concerns on HUPER/LIM
31
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
The full issue of human performance and limitations
were focused to crew members, and only later to
maintenance and other support personnel
Flight crew selection should include human factors
Flight crew management and supervision also
should include human factors
All training needs analysis, task analysis, training
design, validation and development should include
human factors
Safety management systems as part of any
organization should consider human factors
IATA Training & Development Institute
32
Next step in Human factors
Human
performance is
not only a
matter of human
characteristics
and limitations
IATA Training & Development Institute
Case studies
FAA Aeromedical Center Video Spatial
Disorientation
IATA Training & Development Institute
34
33
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Accident Airbus A-320 Bahrain 23/08/2000
IATA Training & Development Institute
Thank you
Session 5
Fatigue and Stress
Introduction
Fatigue and Stress are classical Human Factors
issues
Fatigue and Stress are real threats to Aviation
System since both lead to impaired operator
performance and both have been referred as
factors in accidents
Both share an insidious aspect:
2
TCVT-05 Human Factors in Aviation
The individual inability to recognize the initial
impairment
IATA Training & Development Institute
Session Objectives
The causes and consequences of fatigue
Fatigue risk management system
TCVT-05 Human Factors in Aviation
Personal fatigue management strategies
3
Relationships with Stress
Understanding stress mechanisms
IATA Training & Development Institute
What is Fatigue?
A state of physical or mental weariness that
extend beyond normal tiredness, that
results in reduced alertness
The result of a severe lack of adequate rest
and sleep
4
TCVT-05 Human Factors in Aviation
A sleep debt that accumulates until
paid off with adequate sleep
IATA Training & Development Institute
Other definitions
5
TCVT-05 Human Factors in Aviation
The decrease in performance or performance
capability as a function of time on task (FAA)
A condition characterized by a lessened capacity
for work and reduced efficiency of
accomplishment, usually accompanied by a
feeling of weariness and tiredness. Fatigue can
be acute and come on suddenly or chronic and
persist (Medical Dictionary)
IATA Training & Development Institute
Types of fatigue
6
TCVT-05 Human Factors in Aviation
Physical fatigue concerns the inability to exert
force with ones muscles to the degree that
would be expected.. Physical fatigue most
commonly results from physical exercise or loss
of sleep. Physical fatigue often leads to mental
fatigue.
Mental fatigue, which may include sleepiness,
concerns a general decrease of attention and
ability to perform complex, or even quite simple
tasks with customary efficiency.
IATA Training & Development Institute
Fatigue as HF problem in aviation
Night flying
Transmeridian crossing
Irregular and unpredictable schedules
Long duty days
Early reporting times
Reduced sleep opportunities
Overnight away from home base
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TCVT-05 Human Factors in Aviation
Human alertness and performance is modulated by
sleep need and circadian rhythms
Humans therefore are not designed to operate under the
pressure of 24/7 schedules common in aviation
Fatigue cannot be eliminated from aviation operations
IATA Training & Development Institute
Fatigue challenge
There is a need to develop adequate fatigue risk
management approaches to improve human
performance
Mitigate sleep loss
Enhance alertness during extended duty time
Cope with circadian factors
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TCVT-05 Human Factors in Aviation
In order to reduce/avoid incidents and accidents
in which fatigue is a contributor
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Discussion
What are some
conditions
that make you
feel particularly
tired or fatigued
at work?
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Causes of Fatigue
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Fatigue can be the result of a variety of
factors:
The body’s natural rhythms
Work schedule / shifts
Type of task
Work environment
10
Non work-related issues
IATA Training & Development Institute
The Body Clock
Known as circadian rhythms
Operates on a 24-hour cycle
Makes you sleepy when it’s dark and
awake when it’s light
1500
1800
11
Sleepiness
Digestion
Hormone production
Body temperature
1200
2100
0000
0300
0600
TCVT-05 Human Factors in Aviation
Controls a variety of body functions:
IATA Training & Development Institute
0900
Circadian Rhythms
36.8
36.6
36.4
0600
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
Alertness follows a similar curve – as body
temperature rises, you become more alert
Core body temperature across a 24-hour period
Temp oC
Sleep
Most people need between 7 and
9 hours per day
It’s not true that you need less sleep
as you get older
When you sleep makes a difference
in how much you get
Stage 4
90 to 120 min.
Stage 1
13
Stage 3
Stage 2
TCVT-05 Human Factors in Aviation
Sleep is best obtained in a single block
IATA Training & Development Institute
Sleep Cycles
REM
sleep
Stage 2
Stage 3
14
TCVT-05 Human Factors in Aviation
When you sleep, you cycle through five different
sleep stages
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
Fatigue most common hazards
15
Fatigue usually results in
impaired standards of
operation with increased
likeliness of error
Increased reaction time
Reduced attentiveness
Impaired memory
Withdrawn mood
IATA Training & Development Institute
Fatigue and flight crew
16
TCVT-05 Human Factors in Aviation
Inaccurate flying
Loss of perception
Missed radio calls
Loss of situational awareness
Symptoms of equipment malfunctions being missed
Routine tasks being performed inaccurately or even
forgotten
Falling asleep - either a short "micro-sleep" or for a
longer period
Not looking at details
IATA Training & Development Institute
From an accident report
“Fatigue can lead to forgetting or ignoring normal checks and
procedures, reversion to old habits and inaccurate recall of
operational events. Fatigue can also reduce attention, the effects of
which are that people overlook or misplace sequential task
elements, become preoccupied with a single task and are less
vigilant. When alertness is impaired, people might fix their focus on
a minor problem (even when there was the risk of a major one), they
might fail to anticipate danger and they might display automatic
behaviour syndrome. Problem solving can also be affected, and
flawed logic might culminate in the application of inappropriate
actions.”
17
TCVT-05 Human Factors in Aviation
MK AIRLINES LIMITED BOEING 747 9G-MKJ
HALIFAX INTERNATIONAL AIRPORT, NOVA SCOTIA
14 OCTOBER 2004
IATA Training & Development Institute
Fatigue and Air Traffic Controllers
18
TCVT-05 Human Factors in Aviation
Poor decision making;
Slow reaction to changing situation
Failure to notice an impending confliction
Loss of situational awareness
Forgetfulness
Not looking at details
IATA Training & Development Institute
A Serious Safety Hazard
When you’re fatigued:
Your reaction time is slower
You have trouble concentrating
or remembering things
You may have difficulty communicating clearly with
co-workers
You may fall asleep on the job
There’s a greater risk you’ll make a safety-critical
mistake
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TCVT-05 Human Factors in Aviation
Being fatigued can make you a risk to
yourself, your co-workers, and the public!
IATA Training & Development Institute
As Dangerous as Alcohol?
20
TCVT-05 Human Factors in Aviation
After 24 hours awake, you will be as impaired as if
you were legally too drunk to drive.
IATA Training & Development Institute
Consequences for Health
Fatigue has an important health impact
21
TCVT-05 Human Factors in Aviation
Irritability, stress, anxiety, and depression
Gastrointestinal problems
Cardiovascular illnesses
Reproductive problems
Studies have found that shift-workers
are more likely to suffer from:
IATA Training & Development Institute
Family and Social Life
Working shifts can make you feel socially isolated
– you work while others have fun
Less involved in daily life
Harder to organize domestic chores
Difficulty arranging childcare
Higher risk of divorce
It can take heavy a toll on family:
22
TCVT-05 Human Factors in Aviation
You may be tempted to choose social or family
activities over sleep.
IATA Training & Development Institute
Commuting
One of the most dangerous things you can do
while fatigued is driving a car
You may be driving during the very times that
your body most wants to sleep.
23
TCVT-05 Human Factors in Aviation
Nightshift workers are 4 to 7 times as likely to
have an accident driving home.
IATA Training & Development Institute
Fatigue as a risk in SMS
Pilot fatigue is a significant problem in modern
aviation operations, largely because of the
unpredictable work hours, long duty periods,
circadian disruptions, and insufficient sleep that
are commonplace in flight operations
24
TCVT-05 Human Factors in Aviation
(Fatigue Countermeasures in Aviation; Caldwell
et al. Jan.2009)
IATA Training & Development Institute
Ways of addressing fatigue
Fatigue have been addressed with preventing
measures and rules for minimum crew rest, duty
and flight time limitations (US CFR Part 121 &
135; ICAO Annex 6; EU-OPS Sub. Part Q, etc)
however this has been a controversial issue for
a long time
25
TCVT-05 Human Factors in Aviation
EASA Final Report “Scientific and Medical Evaluation
of Flight Time Limitations” (“MOEBUS Report)
FRMS 2011 ICAO new requirements
IATA Training & Development Institute
FRMS as an element of “evidence
based safety”
26
TCVT-05 Human Factors in Aviation
FRMS appears as an alternate way to address
fatigue instead of applying prescriptive flight time
limitations
This is part of a current thinking around “evidence
based” applied to training and safety in general
Although it appears that no valid scientific evidence
support the more restrictive limitations, there cannot
be statistical inference (and validation) from
evidences if the samples and measurements are not
scientific on their side
IATA Training & Development Institute
ICAO FRMS Standards
27
TCVT-05 Human Factors in Aviation
ICAO has proposed the Council a global standard
for fatigue risk management that might be adopted
by March 2011 and become effective in September
2011
The proposal for the member States will be to follow
prescriptive rigid requirements or adopt a FRMS
under specified conditions
ICAO will provide "clear minimum standards" for an
FRMS, and it has drawn up guidance to help airlines
understand how to meet the standards and
recommended practices
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What is FRMS?
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TCVT-05 Human Factors in Aviation
A continuous process of planning, monitoring
and managing the level of alertness of flight and
cabin crew when performing their duties
Under a FRMS the management has a
responsibility to create a work environment that
minimizes fatigue-related risk, and employees
have an obligation to ensure that time away from
work is used appropriately
FRMS is a risk approach to fatigue and should
work inside an approved SMS
IATA Training & Development Institute
FRMS Components
A fatigue risk management system involves:
29
TCVT-05 Human Factors in Aviation
Policies/responsibilities
Risk assessment
Hazard controls/action plans
Training and education
Ongoing review and improvement (fatigue
auditing and measurements)
IATA Training & Development Institute
Joint Responsibility for Fatigue
Employee Responsibilities
FATIGUE
Organizational Responsibilities
TCVT-05 Human Factors in Aviation
Situation &
lifestyle
Medical
disorders
Non work-related
30
Work-related
Hours of work
Workload &
environment
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31
Hazard control model for FRM
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Level 1 Controls
32
10
TCVT-05 Human Factors in Aviation
30 40
TCVT-05 Human Factors in Aviation
20
12 hour shifts, 7 nights
12 hour shifts / 4 days on, 4 off
Fatigue Likelihood Scores
5
Monday – Friday / 38 hours
0
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Level 2 Controls
Sleep Obtained
TCVT-05 Human Factors in Aviation
Level 2 controls are intended to determine whether
employees actually got the sleep they needed
33
Identifies employees who fail to get
sufficient sleep
Provides a procedure to report fatigue
to a supervisor or manager
Outlines clear steps to take when an
employee makes a fatigue report
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Level 2 Controls
Fatigue Likelihood Score
5 hours
Add 2 points for each
hour below threshold
Add 4 points for each hour
below threshold
Score
X (sleep in prior
24 hours)
12 hours
Prior sleep factor Threshold value
Y (sleep in prior
48 hours)
Y
Add 1 point for each
hour of wakefulness
greater than Y
Z (time awake since
last sleep)
34
TCVT-05 Human Factors in Aviation
A simple calculation can give you a fatigue
likelihood score.
IATA Training & Development Institute
Level 2 Controls
Sample Decision Tree
0
Talk to supervisor and undertake approved individual
countermeasures (i.e., self monitoring for symptoms,
team monitoring by colleagues, task rotation)
No action.
Action
1-4
File fatigue report with supervisor. Organize supervisory checks.
Complete symptom checklist, task re-assignment
Score
5-10
TCVT-05 Human Factors in Aviation
File fatigue report with manager. Do not engage in risky behaviour.
Do not start shift until fit for work.
35
10+
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Level 2 Controls
IFLS Card
0
5-8
1-4
Score
Don’t commence shift until fit for work
Supervisor monitoring
Self-monitoring
Control Level
TCVT-05 Human Factors in Aviation
Refer to FRMS policy for detailed
explanation of controls
9+
Step 4.
Add all points together to determine your score
BACK
2
11h
0
5+h
FRONT
4
4
12+h
Individual Fatigue Likelihood Assessment
8
6
36
Individual Fatigue Likelihood Assessment
12
Step 1. Sleep in prior 24 hours
Sleep
3h
4h
≤ 2h
Points
8
Step 2. Sleep in prior 48 hours
Sleep
≤8h
9h
10h
Points
Step 3. Hours of wake since last sleep
Add one point per hour awake greater
than sleep in step 2.
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Level 3 Controls
Fatigue Symptoms
37
TCVT-05 Human Factors in Aviation
What are some of the common
symptoms of fatigue?
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Level 3 Controls
Fatigue Symptoms
Level 3 controls are intended to identify
employees who show signs of fatigue
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TCVT-05 Human Factors in Aviation
Symptoms of fatigue indicate an increased
risk of fatigue-related error
Employees should watch for symptoms
in themselves and others
A system of reporting allows the company to
take measures when the risk is considered high
IATA Training & Development Institute
Fatigue Proofing Strategies
39
TCVT-05 Human Factors in Aviation
Increased supervisor/co-worker monitoring
Working in pairs
Double-check systems
Checklists
Task rotation
Additional breaks
Napping
Moving critical/monotonous tasks to daytime
IATA Training & Development Institute
Level 4 & 5 Controls
Errors and Incidents
Level 4 & 5 controls consist of:
40
TCVT-05 Human Factors in Aviation
• Fatigue error or incident reporting system
• Investigation procedures to determine whether
fatigue was a cause of an incident
• Review of fatigue management controls
IATA Training & Development Institute
Discussion
41
TCVT-05 Human Factors in Aviation
What strategies do you use to
stay alert when you’re working?
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
Identifying symptoms of fatigue
Physical signs
Yawning
Heavy eyelids; eye rubbing
Mental signs
Loss of concentration
Lapses in attention
Failures in communications
Doing wrong things
Emotional signs
42
Quieter than normal
Lack of motivation / stamina
Irritability
IATA Training & Development Institute
Sleep disorders that require attention
43
TCVT-05 Human Factors in Aviation
Insomnia
Sleep apnea
Restless leg syndrome
Narcolepsy
Body clock disturbances (sleeping during the
day)
IATA Training & Development Institute
Get the Sleep You Need
44
TCVT-05 Human Factors in Aviation
Make it as dark as possible
Make sure the temperature is right: 18°C to 24°C
Move distractions to another room
Make sure you won’t be disturbed
Set up your bedroom for sleeping
IATA Training & Development Institute
Good Sleeping Habits
Keep to a regular bedtime routine
Wind down before trying to sleep
Be careful what you eat or drink before bed
Don’t toss and turn waiting to fall asleep
45
TCVT-05 Human Factors in Aviation
Adjust your bedtime gradually if your shift
changes
IATA Training & Development Institute
Take a Nap
Naps can supplement sleep, not replace it.
Naps 10 minutes or longer can improve
alertness, communication and mood.
The value of a nap doesn’t depend on
the time of day.
46
TCVT-05 Human Factors in Aviation
Allow 5 to 20 minutes for sleep inertia
to pass.
IATA Training & Development Institute
Drink Plenty of Fluids
Dehydration slows you down and increases
feelings of sluggishness.
Working in heat, air conditioning, or at night
can be dehydrating.
Drinking coffee, tea, soft drinks, or alcohol,
and eating salty foods can make you feel
thirstier.
47
TCVT-05 Human Factors in Aviation
Adults should drink at least 2 litres of fluid
a day.
IATA Training & Development Institute
Make Smart Use of Caffeine
Has stimulant effects that can improve
alertness and performance
Best used strategically – only when you
really need help staying awake
Takes 20 minutes to take effect and the
effects can last up to 6 hours
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TCVT-05 Human Factors in Aviation
You can develop both a dependence and
a tolerance
IATA Training & Development Institute
Drugs and Alcohol
Alcohol can help you relax before bed,
but it can also disrupt your sleep
Sleeping pills are best used occasionally
or for only a few days at a time
Cold and flu medication can keep you from
sleeping
49
TCVT-05 Human Factors in Aviation
Always discuss with your Doctor your sleep
disturbance and medication
IATA Training & Development Institute
Eating Right
Maintaining blood sugar levels is key to
controlling ups and downs in energy levels.
Eating low-fat, high-protein foods can
actually increase alertness.
High-fat foods can slow you down.
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TCVT-05 Human Factors in Aviation
High-sugar foods can cause your blood
sugar to rise and fall quickly.
IATA Training & Development Institute
Physical Exercise
Good for your overall health
Can help you sleep better and feel more
rested
Helps relieve stress, boost your health,
strengthen your immune function, and
improve muscle tone and strength
51
TCVT-05 Human Factors in Aviation
Any activity that keeps your heart rate
elevated for at least 20 minutes is good
IATA Training & Development Institute
A Healthy, Balanced Life
Get enough sleep
TCVT-05 Human Factors in Aviation
Spend time with friends and family
Enjoy time for yourself
52
Stay fit and healthy
IATA Training & Development Institute
What is Stress?
53
TCVT-05 Human Factors in Aviation
Stress is a reaction to threatening or
challenging circumstances
Stress is the adverse reaction people have to
excessive pressures or other types of
demand placed on them
There is a clear distinction between pressure,
which can create a ‘buzz’ and be a motivating
factor, and stress, which can occur when this
pressure becomes excessive
IATA Training & Development Institute
A valid definition of Stress
54
TCVT-05 Human Factors in Aviation
The adverse reaction people have to excessive
pressure or other types of demand placed on them
This makes an important distinction between
normal life pressure, which can be a positive state if
managed correctly, and stress which can be
detrimental to health
Stress is state of alarm of our body
It is a response to an emotional or physical threat,
whether actual or imagined
IATA Training & Development Institute
Stress is Biological
All living beings
suffer stress, it is a
natural reaction or
defence
Initially is positive
and creates
conditions for
action
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
Stress and Arousal (Psychological!)
Arousal is a physiological
and psychological state of
being awake or reactive to
stimuli
Arousal is important in
regulating consciousness,
attention, and information
processing.
It is crucial for motivating
certain behaviours, such
as mobility or actions at
work
IATA Training & Development Institute
57
TCVT-05 Human Factors in Aviation
Yerkes-Dodson Law
Performance and Arousal Relationship
IATA Training & Development Institute
58
TCVT-05 Human Factors in Aviation
Performance vs Challenge & Skill Level
IATA Training & Development Institute
Stress Model
STRESSORS
Individual
Group
Organizational
Extra organizational
CHALLENGES
SPECIAL EFFORT
IATA Training & Development Institute
STRESS
THE INDIVIDUAL
59
Personality Mental
Toughness
Age
Gender
Social Support
Physical fitness
IDENTIFY
STRESS
RISK
FACTORS
ORGANIZATION
60
DECIDE
WHO
MIGHT BE
HARMED
EVALUATE
RISKS
CONSECUENCES
Psychological
Behavioural
Cognitive
Physiological
Physical
PEAK
PERFORMANCE
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Managing Work Related Stress
RECORD
FINDINGS &
ACTION
PLANS
MONITOR &
REVIEW
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
Classifying Stressors
External
Environmental
Psychosocial
Work related
Internal
Physiological
Cognitive
IATA Training & Development Institute
Causes of Stress
Threat
Fear
Uncertainty
Cognitive
dissonance
IATA Training & Development Institute
Threats and Fears
A perceived threat will lead a person to feel stressed
Perceived threats can be of any nature:
Physical
Social
Financial
Work related
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TCVT-05 Human Factors in Aviation
The significance of any threat is higher if the person
feels that they have no response or solution
available
Threat can lead to actual fear, and fear to imagined
outcomes which are the real causes of stress
IATA Training & Development Institute
Uncertainty and Cognitive Dissonance
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TCVT-05 Human Factors in Aviation
Uncertainty makes us feeling unsafe, unable to
predict situations and therefore unable to control
Sense of control is very important in perceived
threats and stress
When there is gap between what we do and what
we think we experience cognitive dissonance, that is
also a remarkable cause of stress
Cognitive dissonance is also an uncomfortable
feeling caused by holding two contradictory ideas
simultaneously or two or more contradictory
indications on the same scenario
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65
Stress Environmental Factors
Poor work conditions
Temperature
High noise level
Vibration
Crowded space
Air pollution
Humidity
Altitude
Light
IATA Training & Development Institute
Stress Psychosocial Factors
66
Workplace conflicts
Family conflicts
Lack of time/time pressure
Low job satisfaction
Feeling lack of support
Unrealistic expectations
Financial problems
Loneliness
Devalued self-worth
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Stress Work Related Factors
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TCVT-05 Human Factors in Aviation
Poor management practices regarding workload and
resources
Work patterns
Process planning in the organization
Control and supervision styles
Individual consideration
Inadequate training
Lack of information and data accessibility
Operational pressure at peak hours or non standard
operation
IATA Training & Development Institute
68
Aviation is a Stressful Activity
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
Death: of spouse, family, friend
Health: injury, illness, pregnancy
Crime: Sexual molestation, mugging, burglary, pick-pocketed
Self-abuse: drug abuse, alcoholism, self-harm
Family change: separation, divorce, new baby, marriage
Sexual problems: getting partner, with partner
Argument: with spouse, family, friends, co-workers, boss
Physical changes: lack of sleep, new work hours
New location: vacation, moving house
Money: lack of it, owing it, investing it
Environment change: in school, job, house, town, jail
Responsibility increase: new dependent, new job
Life Causes of Stress
IATA Training & Development Institute
Stress at Work: other views
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TCVT-05 Human Factors in Aviation
The UK's Health and Safety Executive lists six key
stress factors:
1. The demands of the job
2. The control staff have over how they do their work
3. The support they receive from colleagues and
superiors
4. Their relationships with colleagues
5. Whether they understand their roles and
responsibilities
6. How far the company consults staff over workplace
changes
IATA Training & Development Institute
The Signs of Stress
The theory behind
understanding stress is that
if you can recognize the
symptoms, you can manage
it
Signs of stress can be of
varied nature:
71
Emotional and cognitive
Physical
Nervous
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Having marked mood swings
Lack of sense of humor
Eating too much
Eating when you are not hungry
Finding it difficult to concentrate
Not having enough energy to get
things done
Feeling you can't cope
Finding it hard to make decisions
Having emotional outbursts
Generally feeling upset
Emotional-Cognitive Symptoms
Feeling irritable
Feeling frustrated at having to wait
for something
Feeling restless
Unable to concentrate
Becoming easily confused
Having memory problems
Thinking about negative things all
the time
Negative self-talk
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
Sweaty palms
Sweating when not
physically active
'Butterflies' in stomach
Indigestion and 'the
gurgles'
Diarrhea
Unable to sleep or
excessive sleep
Shortness of breath
Holding breath
Physical Stress Symptoms
Muscle tension
Low back pain
Pains in shoulders or
neck
Pains in chest
Stomach/abdominal pain
Muscle spasms or
nervous tics
Unexplained rashes or
skin irritations
'Pounding'
IATA Training & Development Institute
Ways of Managing Stress
Organization
TCVT-05 Human Factors in Aviation
Managers Competences
Processes and Work organization
Information Systems
Training
Continuous Monitoring (integration SMS+HF+QMS+OHS)
Individuals
74
Training on HF and Stress Recognition
Stress Coping Skills
Communication / Teamwork
Risk Perception / Assessment
IATA Training & Development Institute
Natural Coping Mechanisms
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TCVT-05 Human Factors in Aviation
Adaptive: the positive way
Attack: passing the discomfort to others
Avoidance: avoid the issue, denial, escape
Behavioural: changing the way we do
Cognitive: or rational, changing the way we think
Defence mechanisms
Self harm, culpability mechanism, somatization
IATA Training & Development Institute
Positive Stress Coping
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TCVT-05 Human Factors in Aviation
Coping is a set of cognitive and behavioral efforts
aimed at controlling, reducing or tolerating stress
conditions
First pre condition for coping is to be aware of stress
symptoms
Coping strategies may be focused either in solving
the problem (avoiding stress situation) or mitigating,
that is building up defenses or reorganizing tasks in
a team
That´s why Stress is in CRM Training Programs
Request help or support anytime you feel stressed!
IATA Training & Development Institute
Stress and Individuals
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TCVT-05 Human Factors in Aviation
Stress is a normal physical response to events
that make you feel threatened or upset your
balance in some way
As such is variable; stress signs and reactions
are individually determined
The question is if you are controlling stress or
stress is controlling you
IATA Training & Development Institute
How do you respond to stress?
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TCVT-05 Human Factors in Aviation
Foot on the gas – An angry or agitated stress
response. You’re heated, keyed up, overly
emotional, and unable to sit still
Foot on the brake – A withdrawn or depressed
stress response. You shut down, space out, and
show very little energy or emotion
Foot on both – A tense and frozen stress
response. You “freeze” under pressure and can’t
do anything. You look paralyzed, but under the
surface you’re extremely agitated
IATA Training & Development Institute
Other Important Stress Issues
Critical Incident Stress Management
Crisis / Disaster intervention on Human Factors
Post Traumatic Stress
ERP Psychological Support and Intervention
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http://www.icisf.org/
http://www.atss-hq.com/
http://www.cismcare.com/
http://www.cisresponse.com/l
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81
Thank you
TCVT-05 Human Factors in Aviation
Human Cognition and Decision
Making
Session 6
2
TCVT-05 Human Factors in Aviation
Our Vision of the Outside World
Our motivation for action
Our behaviour
What this Section is about?
IATA Training & Development Institute
The way we think
3
TCVT-05 Human Factors in Aviation
How we think is as important as what we think
The internal working of our minds have long
been mysterious but we understand our mental
processes much better today than we did 20
years ago
The key issue here is to understand why we do
what we do
IATA Training & Development Institute
Information Processing
4
TCVT-05 Human Factors in Aviation
We refer to this as “human information
processing” or HIP
Cognitive Psychology / Applied Cognition
HIP is experimentally related with decision
making and human performance
IATA Training & Development Institute
Cognition
5
Term related to thinking,
reasoning, knowledge
processing, human
information process, and in
general complex mental
processing
Collins COBUILD Dictionary:
the mental process of
knowing, learning and
understanding things
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Mental information processing and
safety
6
Understanding HIP is a
key Human factors
issue necessary to
improve safety
It is great evidence
that human information
processing have
contributed to many
aviation accidents
IATA Training & Development Institute
Everything starts with perception
7
TCVT-05 Human Factors in Aviation
To understand human information processing
researchers use the metaphor of a computer
Simply speaking this model considers the brain
as a “black box” that receives INPUTS do
internal processing and provides OUTPUTS as
performance
The main stream of sensory inputs combine in a
complex initial process called PERCEPTION
IATA Training & Development Institute
How we process information
8
TCVT-05 Human Factors in Aviation
Perception is always linked to memory
Memory is divided into three stores: the sensory, the
short-term, and the long-term
This model represents how we acquire, relate, make
sense and use the outside world information in our
mind to understand what’s going on and to react
Research says that we get inputs from our sensory
system, filter or process this information making use
of memory buffers, and make decisions
IATA Training & Development Institute
TERM
SHORT
LONG
TERM
9
TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
DATA OUTPUT
COMMUNICATION
ACTION /BEHAVIOUR
10
DATA CACHE / MEMORY
STORAGE
SENSORY
DECISION MAKING
PROCESS
FILTERS / BIASES
MENTAL MODELS
MENTAL CPU
The basic functional model
DATA INPUT
IATA Training & Development Institute
Cognitive Model
IATA Training & Development Institute
11
TCVT-05 Human Factors in Aviation
Flying is Information Processing
IATA Training & Development Institute
General Principles on Cognition
12
TCVT-05 Human Factors in Aviation
The first is the assumption of a limited capacity of the
mental processing system
A second principle is that a control mechanism is required
to oversee the encoding, transformation, processing,
storage, retrieval and utilization of information
A third principle is that there is a two-way flow of
information as we try to make sense of the world around us
We constantly use information that we gather through the
senses and information we have stored in memory in a
dynamic process as we construct meaning about our
environment and our relations to it
IATA Training & Development Institute
Types of memory
We are not consciously aware of most of the things
we perceive; we become aware of them only if we
consciously direct our attention to them
When we do focus our attention on them, they are
placed in our working memory
Working (or short term) memory has a very little
capacity, we normally can attend to only seven items
at a time from 3 to 20 seconds
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To remember things you will only need for a short time,
such as the phone number you’re dialing
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Long term memory
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Stores information and knowledge for a long
time, apparently there is no size limit on it
To remember things you will use over and over
such as, how to operate you car
To make use of the stored information we must
move it back to working memory in a process
called retrieval
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TCVT-05 Human Factors in Aviation
LIMITED !
Wickens' Model of Human Information
Processing
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Memory leaks
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WE ALWAYS WORK WITH
INCOMPLETE INFORMATION !
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The key is perception
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Perception involves the association of meaning to
sensory stimuli
The two most important issues here are:
The problem of signal detection and patter
recognition
The problem of selection of a mental model to
understand the relevant information
Sensory information when flying an aircraft is very
large and complex: the pilots must select the most
relevant, decode, associate and compare with
stored data to make sense and react accordingly
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Mental process
To connect and to be aware of what happens to us
at every moment
To process available information comparing with
internal models and memory (our knowledge)
To evaluate the reality and to orient our actions in an
efficient way (make decisions)
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To control our reactions and behavior (feedback)
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Cognition Component
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TCVT-05 Human Factors in Aviation
Attention
O Memory
Perception
Cognition is related to the operation of the mind
Language
LT Memory
Judgement
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Related mental processes
Mental models and
mental pictures
Situational awareness
Decision-making
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Mental Models
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Mental Models
TCVT-05 Human Factors in Aviation
Our prior knowledge
of pictures and
faces allow us to
see a "face" in the
word "Liar"
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It is a representation of the surrounding world, the
relationships between its various parts and a
person's intuitive perception about their own acts
and their consequences
Our mental models help shape our behaviour and
define our approach to solving problems and
carrying out tasks
Is generally founded on incomplete facts and
information
Effects as a filter, causing selective perception
We often consider this as “the reality”
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•Objects
•Scenes
•Order of Events
Foundation for:
Mental Model
Cue
Modifies/ refines
Cue
Creates
Mental Scaffold or Framework:
Mental Models
External
Cues
Meaning
Simulation in mental
model predicts:
Future
Cues
Situational Awareness States of
Perception
Modelling
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Mental modelling is used by humans to
understand reality and make decisions
All models are incomplete and a compromise
The model maker's art lies in making those
trade-offs that will render the model most useful
to the problem at hand
That necessary means a quick refresh rate to
update the model with real feedback from
outside world including people
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Mental Picture
Is a representation of a situation in a moment-tomoment snapshot of the actual situation based
on the mental model and the actually perceived
external cues
Is closely related with
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TCVT-05 Human Factors in Aviation
Situational Awareness SA
Decision making
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What is the issue with HIP?
Situational
Awareness
TCVT-05 Human Factors in Aviation
Dynamic
mental
picture
Decision
Making
27
We do not intent in this course to go on the
details of Neuroscience or what part of the brain
is involved in what
The issue here is to understand the source of
problems, the vulnerabilities
To help us in designing/operating for improved
human performance
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External
world inputs
External
actions
The process layout
Performance
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TCVT-05 Human Factors in Aviation
Vulnerabilities: basic HF like perception errors, cognitive
biases, fatigue, stress, personality
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Situational Awareness
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It’s a key issue on Human Factors in aviation
SA has been identified as one of the primary factors
in accidents attributed to human error
The perception of elements in the environment within
a volume of time and space, the comprehension of
their meaning, and the projection of their status in
the near future
SA is a cognitive process: perception, meaning,
projection
As such It is subject to bias from several influences
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SA Definitions
Endsley (Researcher speak) :
“The perception of elements in the environment within
a volume of time and space, the comprehension of
their meaning, and the projection of their status in the
near future”
Pilot speak:
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TCVT-05 Human Factors in Aviation
Perceiving the features of the environment
Knowing what they mean relative to the flight
Projecting their status into the future
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SA in short
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TCVT-05 Human Factors in Aviation
Keeping track of what is going on around you in
a complex, dynamic environment,
What you need to know not to be surprised
For a pilot: flying ahead his aircraft
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Elements of SA
Perception
Comprehension
Projection
Space
Time
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SA Levels
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TCVT-05 Human Factors in Aviation
Level 1: Perception: Simply noticing features in
the environment
Level 2: Meaning: The assignment of meaning
to those features
Level 3: Projection: Mentally simulating the
status of those features in the future including
risk assessment (what can wrong)
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35
Action
Perception
Level 1 -Cues
noticed by the
crew
Level 3:
Projection
of Future
States
TCVT-05 Human Factors in Aviation
Decisions
Drives
Level 2:
Meaning
given to
cues
Situation Awareness
Endsley’s Situational Awareness Model
Environment
Acts on
and modifies
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Team SA
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TCVT-05 Human Factors in Aviation
In aviation people usually work in teams
A team means a group of persons interacting
toward a common goal
Team SA is the degree to which every team
member possesses the SA required for her/his
responsibilities
Requires a shared mental model, shared rules
and common language
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37
Heuristics and Biases
The study of
reproducible errors of
human reasoning, and
what these errors
reveal about
underlying mental
processes, is known
as the heuristics and
biases program in
cognitive psychology
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Cognitive Biases
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TCVT-05 Human Factors in Aviation
Cognitive bias is a general term that is used to
describe many distortions in the human mind that
are difficult to eliminate and that lead to perceptual
distortion, inaccurate judgment, or illogical
interpretation
Biases could be defined as reasons what you think
right is wrong
In our HIP model cognitive biases are distortions of
the mental picture about reality caused by filters or
influencing patterns in the perception of situations
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The most studied and known biases
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TCVT-05 Human Factors in Aviation
Bandwagon effect: the tendency to do things
because many other people do (group think)
Confirmation bias: the tendency to search for
information or cues that confirm one´s
preconceptions or hypotheses
Availability bias: using the most near information
available
Framing effect
Illusion of control
Wishful thinking
Halo effect
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Not a simple issue
Bias blind spot: the
tendency to see
oneself as less biased
than other people
Teamwork, CRM,
team SA and
metacognition help in
keeping better guess
about reality
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Example Biases in Operations
Availability Bias – Situation is interpreted using
the easiest explanation to generate
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TCVT-05 Human Factors in Aviation
Conflicting cues can be ignored or missed.
When applied to generating options – explains why
snap judgments occur
Experts can be susceptible to availability bias via their
use of recognition strategies
Time pressure is conducive to availability bias
High task workload is conducive to availability bias
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Bias in Operations
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Plan continuation bias is the tendency of
people to continue to follow their original plan,
even in the face of evidence that the
circumstances have changed
Apparently, we have an unconscious bias in
thinking that leads us to follow our original
course of action, particularly when we are close
to the end.
Examples and cases; AF Toronto; FSF ALAR
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Bias mitigation
Confirmation bias:
Use bottom up processing
Argue against continuing rather than for continuing
Identify assumptions used in the assessment process
– critique them
Base rate neglect bias:
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TCVT-05 Human Factors in Aviation
Know the accurate probabilities of event occurrence.
Exercise good risk assessment skills.
Exercise good risk management skills.
Collect others’ visions on the same situation
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Bias mitigation -2 Availability bias:
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TCVT-05 Human Factors in Aviation
Broaden profession specific knowledge – fewer
conflicting cues will be missed.
Make good use of team SA processes – assumptions
are critiqued, more options identified.
Understand the effects of time pressures on
assessment and option generation. Make more time.
Avoid task saturation – make time, schedule tasks
better.
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Influences on SA
Personal,
Corporate Goals
Modifies
Action Choice
Determines
Appropriate
Situation
Assessment
Data Drives
Environment,
Aircraft,
Personal
Bottom Up
Processing
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General conclusions
46
Top Down
Processing
Environment,
Aircraft,
Personal
Filtered Through
Personal,
Corporate Goals
Influences
Flawed Situation
Assessment
Drives
Poor Action
Choice
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TCVT-05 Human Factors in Aviation
Situation assessment training should include
training on cognitive biases and on
metacognitive skills
Evaluators should keep in mind the influence of
biases when diagnosing crew behaviors
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Decision Making
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TCVT-05 Human Factors in Aviation
The selection of one choice from a number of choices
Information is available with respect to the choice
Time is available to make a choice
The choice is associated with a level of uncertainty
Decision Making is a key element in the
information processing by the humans and is
related with:
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DM and Risks
48
Decision making training
is a way of reducing
human errors and bad
decisions that results in
poor performance
Decision making should
be related to ORM
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TCVT-05 Human Factors in Aviation
Human Error and Decision-Making
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(Rasmussen, 1993; Reason 1991)
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Types of Decision-Making
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Normative DM: human decision making against
rules
Prescriptive DM: human decision making using
decision aids
Descriptive or Naturalistic DM: based on how
experts make decisions
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Normative DM
TCVT-05 Human Factors in Aviation
Heuristics: shortcuts or rules of thumb that
specify the relationship between phenomena
based on experience
Mechanisms that reduce the demands on
information processing
Based on previous mental models
Subject to biases and errors
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Representativeness bias
Availability bias
Confirmation bias
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What happens with quick DM?
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Humans are not particularly accurate in
estimating the frequency of probabilistic events
Humans prefer to use decision strategies that
minimise the application of cognitive resources
Humans often use intuition when making
decisions
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Prescriptive DM
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TCVT-05 Human Factors in Aviation
Models or procedures that advocate the
application of cognitive resources to ensure that
all of the information available is acquired and
processed, and that the decision that is arrived
at is logical and rational
Examples:
DECIDE
FORDEC
GRADE
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FACTS
OPTIONS
RISKS AND BENEFITS
DECISSION
EXECUTION
CROSS-CHECK
FORDEC
•F
•O
•R
•D
•E
•C
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D
E
C
I
D
E
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Gather the facts
Review the information
Analyze the options
Decide on a response
Evaluate the outcomes
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Detect that a change has occurred
Estimate the extent of the change
Choose an appropriate goal
Identify an appropriate strategy
Do
Evaluate the outcomes
DECIDE
•
•
•
•
•
•
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G
R
A
D
E
GRADE
•
•
•
•
•
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Prescriptive DM in a snapshot
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The accuracy of the outcome is the priority
The scarcity of time or time pressure is a factor
It should be a rational process using the
available cognitive resources
Reminders and nemotechnic’s are used as an
aid
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Naturalistic DM
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Models that have been developed on the basis of
descriptions of decision-making in a range of
contexts
Based on expert decision-makers
Through experience, expert decision-makers have
developed the skills necessary for accurate and
efficient decision-making
Firefighters
Military
ATCO
Pilots
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Diagnose a situation quickly
Detailed understanding
Process information unconsciously
‘Recognise’ a situation
Repertoire of experiences
Experts
Process information in sequence
Unable to diagnose a situation
Limited understanding
Process information consciously
‘Analyse’ a situation
Few experiences
Novices
Descriptive Approaches to Decision-Making
Chunk information
TCVT-05 Human Factors in Aviation
Analytical (Knowledge-Based)
Cannot Improvise
59
Can Improvise
Intuitive (Skill-Based)
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Recognition-Primed Decision Theory
(Klein)
Experts possess a repertoire of exemplars/ cases that are
‘triggered’ by cues within the environment
The ‘most similar’ case is considered in terms of its
application
RPD combines two ways of developing a decision
The first is recognizing which course of action makes sense
The second, evaluating the cause of action through imagination to
see if the actions resulting from that decision make sense
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However, the difference of being experienced or
inexperienced plays a major factor in the decision-making
processes
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The value of cues
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Cues represent signals or reminders that occur
within a particular context
They may be visual, auditory, olfactory, or
tactile, or proprioceptive in nature (internal; gut’s
perception)
In decision making, cues are presumed to act as
a trigger for diagnosis or a trigger for a response
This is closely related with mind models ,
memory and retrieval processes by associations
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Naturalistic Decision Making
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The NDM framework focuses on cognitive functions such as
decision making, sensemaking, situational awareness,
planning – which emerge in natural settings and take forms
that are not easily replicated in the laboratory or the
simulators
The effort is devoted to situation assessment or figuring our
the nature of the problem;
Single options are evaluated sequentially through mental
simulation of outcomes; and
Options are accepted if they are satisfactory, rather than
optimal
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The Real World in NDM
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Problems tend to be ill-structured and information
always incomplete
The conditions are uncertain and dynamic
The multiple goals may be ill-defined, may be in
conflict, or may shift over time
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NDM is highly interactive
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There are action and feedback loops
Decisions are not discrete events but happen
amidst the flow of activity in a system and are
impacted by the decisions and activity that
precede them
Decision makers must respond in real time to
changes in the system
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Other issues in NDM
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NDM often involve high stakes
Multiple players interact in the decision-making
process
NDM typically involves activities that are embedded
in organizations
Culture manifested in accepted norms, policies,
guidelines, directives, standard operating
procedures, and doctrine
Communicated explicitly (verbally or in written
documents) or implicitly (through behavioral
modeling or system design)
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TCVT-05 Human Factors in Aviation
A real scenario in decision making
In real operations we never
have ALL he required
resources:
Time
Information
Equipment
Energy
Space
66
Human operators always try
to balance demands and
resources
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Operational (Business) Pressure
TCVT-05 Human Factors in Aviation
Aviation business is under many forces and operators
seek at the same time safety and quality objectives
You can try to do it FAST, CHEAP and GOOD, but
normally you only are able to make TWO of the three
As a result we always have to make a trade-off between
efficiency and thoroughness (the ETTO Principle)
ETTOing involves the application of certain “rules of
work” like:
67
It looks fine, we can skip the rest
It is not my responsibility
It has been checked by someone before
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A FEW SLIDES ON
PERCEPTION
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How old is she?
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Where is the elder?
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TCVT-05 Human Factors in Aviation
Which of the two red circles is bigger?
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What do they see?
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TCVT-05 Human Factors in Aviation
What do they see?
73
A few words on remedies
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To remedy errors in perception, mental
modelling, situational awareness and decision
making, CRM is not the only remedy
We need to develop new skills to understand the
way we think and its shortcomings
We call that METACOGNITIVE SKILLS
Metacognition refers to peoples' automatic
awareness of their own knowledge and their
ability to understand, control, and manipulate
their own cognitive processes
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What is metacognition?
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Metacognition has been described as the
awareness of one's own knowledge and the ability
to understand, control, and manipulate one's own
cognitive processes
This way “metacognition” becomes an essential
Human Factors skill for workers and managers,
specially in high risk industries (KDM)
Metacognition is influenced by personality factors,
culture and training
Metacognition is a part of critical thinking, self
criticism and retention of safety knowledge
(development of expertise)
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Metacognitive Skills
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Metacognitive skills are not only important for
trainers and learners at school, but throughout
life for everyday business
It is essential that an effective manager be a
person who has learned to learn
That is true also for pilots and any skilled
operator
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Enhancing expertise
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Metacognition is essential to enhance expertise
An expert is a worker who mentally generates
abstract representations of internalized factors in
dealing with reality, and make decisions based on
in-depth understanding of workplace situations
Modelling and simulation based on experience are
the key for quick situational awareness and decision
making
The decision to assess operational emerging risks,
performing a checklist or producing an effective
briefing is not only a matter of following procedures
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Current training on flight simulators
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The training on state-of-the-art, sophisticated simulators
can be ineffective if not applying metacognition and
enhanced learning
In spite of all the complexity the current simulators are
not a 100% representation of real world conditions
Pilot´s passing their recurrent training with success are
very skilled persons, but they can get a false sensation
of being trained for everything that might happen, since
training is normally 100% successful and reinforcing
Pilots and Instructors require then critical thinking and
metacognitive analysis to make real value from training
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79
Thank you
TCVT-05 Human Factors in Aviation
Human Error
Session 7
HUMAN
ERROR
Marcus Tullius Cicero
106-43 B.C.
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TCVT-05 Human Factors in Aviation
“To err is human”
IATA Training & Development Institute
3
TCVT-05 Human Factors in Aviation
Are errors causes or symptoms?
“Knowledge and error
flow from the same
mental sources, only
success can tell the
one from the other”
Ernst Mach (1905)
IATA Training & Development Institute
Human Error
After many human factors accidents in the 70’s
PILOT ERROR was defined as “an enigma” *
For years the term Human Error (or Pilot Error) have
been overused as an simplification for human
factors involved in accidents
It was some years later when such authors as Dr.
James Reason, Dr. Sydney Dekker, Dr. Erik
Hollnagel, Dr. Jens Rasmussen and others (just to
mention some European researchers) started
publishing research on human error
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* Pilot Error: A professional study of contributory factors; Ed. By Ronald Hurst (1976)
IATA Training & Development Institute
The context for errors
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Errors cannot be studied as a separate category
of human behavior fragments but must be
viewed within work-organizational context
In short, errors can be seen as the difference
between an actual state and desired state
Current research on human error have changed
the focus from individual behaviour to the task
and social context in which any error may occur
IATA Training & Development Institute
Human Error analysis
The problem of human error can be viewed in 2
ways:
The person approach
The system approach.
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TCVT-05 Human Factors in Aviation
Each has its model of error causation, and each
model gives rise to different ways of error
management.
Understanding these differences has important
practical implications for coping with the everpresent risk of mishaps in aviation
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Person Approach
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It focuses on the unsafe acts—errors and
procedural violations—of people on the front line:
flight crew, mechanics, loaders, dispatchers, etc.
Errors in this context are related to individual human
information process and related biases,
forgetfulness, inattention, distractions, poor
motivation, carelessness and other cognitive issues
The associated countermeasures are directed
mainly at reducing unwanted variability in human
behavior
IATA Training & Development Institute
What is an error?
8
Errors are about human
performance: wrongdoing or
undesired effects
The threshold of what is
error or not is quite arbitrary
depending on the person
making the judgement and
the context of behaviour
Unacceptable or acceptable
are expressions that need to
be within some action
context
IATA Training & Development Institute
Some Definitions
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James Reason “Human Error” (1990)
Error could be taken as a generic term to
encompass all those occasions in which a planned
sequence of mental or physical activity, fails to
achieve an intended outcome, and when these
failures cannot be attributed to external chance
occurrence
We fail to achieve desired outcome because the
actions did not go as planned or because the plan
itself was inadequate
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System Approach
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The basic premise here is that humans are fallible and
errors are to be expected, even in the best organizations
Errors are seen mainly as consequences rather than
causes
There is no a simple framework for errors, and so
organizational LATENT ERRORS interact or condition
the sharp end ACTIVE ERRORS made by people in
front
Countermeasures here are based on the assumption
that although we cannot change the human condition,
we can change the conditions under which humans work
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11
How is Human Error Mitigated
Improvements in
technology
contribute to
aviation safety by
reducing the
opportunity for
human error
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12
The Operating Point
Pressures to
increase
productivity
and avoid high
workload push
the system
operating point
towards
compromised
performance
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
The margin for error: resilience
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Organizations seek to create a boundary of
operations that allows for variable performance
without causing loss
A high level human factor activity is needed to
understand where one’s operating point is
relative to the unacceptable performance margin
Going across that margin means an adverse
outcome
IATA Training & Development Institute
Resilience and Errors
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The operating margin is somewhere related with
the interaction of organization’s and personal’s
errors
Resilience is the ability of the system to
accommodate for possible errors, normally
unpredicted, and cope with new situations
keeping the system safe or ready after a failure
IATA Training & Development Institute
The human error with a face
15
The person approach remains
the dominant tradition in
human factors in aviation
Blaming individuals failures as
“human error” is easier than
targeting large organizations
However the individual study
of human error can help us
understanding how errors
grow also at organizations
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
Human Error and Performance
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Human error has been cited as a cause or
contributing factor in many accidents and
incidents
It is important to stress that "human error"
mechanisms are the same as "human
performance" mechanisms
So actions later termed "human error" are
actually part of the ordinary spectrum of human
behaviour
IATA Training & Development Institute
A cognitive field for Human Error
The cognitive study of human error is a very
active research field not only in aviation
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The limits of memory and attention
Situational awareness
The decision making strategies such as the
availability heuristic and other cognitive biases.
Such heuristics and biases are strategies that are
useful, but can lead to systematic patterns of error
IATA Training & Development Institute
Slips and Lapses
18
Slips and lapses are forms
of error which result from
some failure in the
execution stage of an action
sequence, regardless of
whether or not the plan
which guided them was
adequate to achieve its
objective
IATA Training & Development Institute
Slips and Lapses examples
Slip of the tongue
Slips of the pen
Automatic slips of action
Slips and lapses occur while our attention is diverted
and we fail to monitor the actions we're performing
Common slips on modern aircraft handling:
Entering wrong data on flight computers to calculate take
off weight and speeds
Changing a – by a + on FMS
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COGNITIVE STAGE
Mistakes
ERROR TYPE
TCVT-05 Human Factors in Aviation
However: remember CONTEXT (fatigue,
distractions, stress, time pressure, ETTO…)
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Planning
Lapses
Primary Error Types
Storage
TCVT-05 Human Factors in Aviation
Slips
20
Execution
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How to avoid action lapses
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HARDWARE: Safety guard on essential switches
Human Centred Design
IATA Training & Development Institute
Software and Liveware solutions
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Are you sure you want to delete the file?
Electronic Check Lists
Written procedures: SOP, callouts, paper
checklists, crew monitoring, verbalizing
plans and intended actions, briefings
Crosschecking
Avoiding distractions: e.g. Sterile Cockpit
Human centred design in general
IATA Training & Development Institute
Examples: reduction of slips and lapses
23
No
Yes
Intentional but
mistaken action
Unintentional
action (slip or
lapse)
Spontaneous or
subsidiary action
Involuntary or
non-intentional
action
TCVT-05 Human Factors in Aviation
Controlling factors that are known to contribute to
errors, such as unnecessary distractions; sterile
cockpit principles aim to reduce distractions
An airline was worried about several instances in
which flight crews failed to set flaps to the correct
takeoff flap settings and had to be reminded by the
takeoff configuration warning. In response, the
airline changed the checklists to place the flap item
before the taxi phase, avoiding distractions
encountered while taxiing
Safety culture: the meaning of risk management
IATA Training & Development Institute
No
No
No
Was there
intention in the
action?
Slip, lapse or mistake?
Was there prior
intention to act?
Yes
Did the actions
proceed as
planned?
Yes
Did the actions
achieve their
desired end?
Yes
Successful action
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TCVT-05 Human Factors in Aviation
Violation: when one
intentionally deviates from
regulations, norms or
procedures
A violation is intentional and
can become routine or an
inappropriate norm
VIOLATIONS
Errors and Violations
R
ER ORS
Error: when an action
deviates from the
intention, or when its
intention is
inappropriate
An error is not
intentional
IATA Training & Development Institute
Relation Between Active and Latent
Errors
Information
upon
the events
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TCVT-05 Human Factors in Aviation
To address latent error is the best approach
for management to reduce errors
IATA Training & Development Institute
Performance Levels and errors types
Skill based level
Human performance is governed by stored patterns
Errors related to the variability of conditions
Rule based level
Familiar problems solved with stored rules
Errors relate to the misclassification of situation or the
incorrect recall of procedures
Knowledge based level
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For novel situations applying stored knowledge
Errors arise by incomplete knowledge or resource limitation
IATA Training & Development Institute
Skill based level
PERFORMANCE LEVEL
RB mistakes
Slips and Lapses
ERROR TYPE
Reason’s Generic Error Modelling
System (GEMS)
Rule based level
TCVT-05 Human Factors in Aviation
KB mistakes
28
Knowledge based level
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29
Real Situations and Modes
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TCVT-05 Human Factors in Aviation
Failure Modes at Skill Based Level
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Inattention – omitted checks
Omissions associated with interruptions
Reduced intentionality
Perceptual confusions
Interferences
Over attention, mistimed checks
IATA Training & Development Institute
Failure Modes at Rules Level
Misapplication of good rules
During a series of alerts and warnings the Captain sees
the GENERATOR OFF light on, and he commands the
First Officer: “Generator Failure Procedure”
However the generator light was ON because the
associated engine had failed; he should have commanded
“Engine Fail Procedure” first
The application of bad rules
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After an engine shut down, the crew try to relight the
engine at a higher altitude than prescribed on the FCOM
Obviously the engine did not start
IATA Training & Development Institute
Failure Modes at KB Level
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Selectivity
Workspace limitations
Out of sigh out of mind (availability heuristic)
Confirmation bias
Overconfidence
Illusory correlation
Halo effect
Complexity
Knowledge base limitations
Memory failures – retrieval limitations
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J. REASON’S HUMAN
ERROR
IATA Training & Development Institute
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Human Factors Analysis and
Classification System (HFACS)
34
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The Human Factors Analysis and Classification
System (HFACS) was developed initially as a
framework to understand "human error" as a
cause of aviation accidents (Shappell and
Wiegmann, 2000; Wiegmann and Shappell,
2003)
It is based on James Reason's Swiss cheese
model of organization accidents
IATA Training & Development Institute
Reason´s Model
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The Swiss cheese model of system
errors
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The model is based on how the different layers
of defences, barriers and safeguard can fail
providing it’s function
The system recognizes active failures, as the
unsafe acts committed by people on the front
line and also latent conditions on the
organization that can facilitate the human errors
36
at the sharp end Swiss Cheese
Model
IATA Training & Development Institute
HFACS in a flash
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HFACS distinguishes between the "active
failures" of unsafe acts, and "latent failures" of
preconditions for unsafe acts, unsafe
supervision, and organizational influences
These categories were developed empirically on
the basis of many aviation accident reports.
IATA Training & Development Institute
Unsafe Acts
Unsafe acts are performed by the human
operator "on the front line" (e.g., the pilot, the air
traffic controller
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TCVT-05 Human Factors in Aviation
Errors: in perception, decision making, skill based or
knowledge based
Violations: routine or exceptional
IATA Training & Development Institute
Preconditions for Unsafe Acts
Human operator internal state
Physiological
Mental state (cognitive)
Competence mismatch, overload
Human operators practices
39
Poor operators practices
Poor professionalism or airmanship
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Unsafe Supervision
40
Inadequate supervision
Planned inappropriate operations
Failure to correct a known problem
Supervisory violations
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Organizational Influences
42
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Resource allocation and management
Organizational climate and culture
Organizational processes
Procedures
Schedules or rosters
Management oversight
Proficiency checking
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HFACS
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TCVT-05 Human Factors in Aviation
Human Errors happen to people
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Modern view of Human Error*
When you are faced with human error problem you
can take two distinct directions:
You can see human error as the cause of a mishap
There are hundreds of accident and incident reports with
probable cause: human error
You can consider human error as the sign of deeper
problem
In this case finding an error is just the beginning or staring
point for investigation
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Dr. Sydney DEKKER, The Field Guide to Understanding Human Error (2006)
IATA Training & Development Institute
Two views on human error
The old view: human error is the cause of the problem
Systems are basically safe but unreliable people or bad
professionals make it unsafe
“Bad Apple” theory: throw away the bad apple from the basket)
The new view: Human error is a symptom of trouble
deeper inside a system
To explain failure do not try to find who to blame for
Instead find how people’s assessment and actions made sense
at the time, under the circumstances that surrounded them
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TCVT-05 Human Factors in Aviation
Human error then is not anymore an explanation for
trouble, on the contrary it demands an explanation
IATA Training & Development Institute
What happens at investigations?
Under the “old view of human errors” what we
observe as recommendations is:
Separate the bad performers
Tightening procedures or adding new ones
Closing the regulatory gap or adding requirements
Introducing more technology to monitor humans
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Adding complexity to the system represents
actually more risk for human performance
Adding or enforcing existing procedures does
not guarantee compliance
IATA Training & Development Institute
Complex Systems
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TCVT-05 Human Factors in Aviation
Complex systems as Aviation are not intrinsically
safe
They are trade-offs between multiple
irreconcilable goals, like safety/efficiency, or
efficiency/thoroughness
You don´t buy or provide built-in safety
People have to create safety through practice
Then safety is an emergent and dynamic
property of the system
IATA Training & Development Institute
Two stories
Underneath every simple story about a so called “human
error” there is a deeper, more complex story
This second history is inevitably an organizational story,
about the system we have created in which people work
In such organizations safety is never the only goal
In aviation sometimes safety is taken for granted (silos)
Director of Operations and Director of Maintenance are assuring
the quality
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TCVT-05 Human Factors in Aviation
Organizations exist to create value and revenue (profits)
Production pressure is high, resources sometime scarce
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Production pressure
TCVT-05 Human Factors in Aviation
Production or operations pressure in aviation is
quite high:
49
Economic pressures, efficiency
Schedules
Competition
Customer service
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Errors under Pressure
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TCVT-05 Human Factors in Aviation
This influences people’s trade-offs, making
normal or acceptable what previously was
irregular or unacceptable
Here lies the complexity of human factors in
aviation
When something goes wrong everybody blames
the other and eventually the last frontier is at the
sharp end: the one making the last decision near
the accident
IATA Training & Development Institute
Illusion of control in management
Human errors are labelled or related to conditions
like:
Loss of situational awareness
Bad decision making
Bad planning
Complacency
Lack of professionalism
Negligence
Poor proficiency
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TCVT-05 Human Factors in Aviation
If your effort ends here you are probably missing the
real story behind failure
IATA Training & Development Institute
Local rationality
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TCVT-05 Human Factors in Aviation
We should assume that normal people at normal
environments, like in aviation, don´t want to produce
accidents: nobody comes to work to do a bad job
Every pilot wants to land safe and have a nice flight,
the same as the passengers
So after any incident or accident , to make sense
and understand human errors we need to
understand WHY it make sense to them doing what
they did
This is known as local rationality principle
IATA Training & Development Institute
Unreliable people or system bad
management?
We observed looking at accidents reports that
sources of error are mostly structural, systemic,
not personal (although human performance
limitation is always present)
Colgan Air: example
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“Rather than being the main instigators of an accident, operators
tend to be the inheritors of system defects. Their part is that of
adding the final garnish to a lethal brew whose ingredients
have already been long in the cooking.”
Dr. James Reason
IATA Training & Development Institute
Session Review
“We cannot change the human condition, but we
can change the conditions under which humans
work.” (James Reason)
How to reduce human errors
How to manage human errors in organizations
The deep look approach after mishaps
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The preventive approach, how to apply Human
Factors wisely in a Risk Management integration
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IATA Training & Development Institute
55
Thank you
TCVT-05 Human Factors in Aviation
Session 8
Teamwork and CRM
Teamwork
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A set of behaviours, cognitions and attitudes that
are enacted in order to achieve mutual goals and
meet the demands of the outside environment
Normally in organizations we work in teams
Crew
Maintenance
Loaders
Controllers
Dispatchers
Managers
Committees
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3
TASKWORK
TEAMWORK
Two Tracks of Skills Needed
SKILLS IN
TEAMS
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PERFORMANCE
TCVT-05 Human Factors in Aviation
How to improve Team Performance
Teambuilding
TCVT-05 Human Factors in Aviation
The vision of the organization
Common shared values, group culture & corporate
culture
Roles
Plans and strategy
Bonding and developing of the team
Training
4
Team Resource Management TRM
IATA Training & Development Institute
What is TRM?
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Team Resource Management is a derivative of
original works on Cockpit and Crew Resource
Management in the US in the 1980’s at NASA
Ames research centre
Commercial and military aviation have been
utilizing crew resource management (CRM)
training for more than 2 decades
CRM is an instructional strategy that trains
crews to effectively use all of their available
resources in a HF context
IATA Training & Development Institute
CRM is Applied Human factors
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Crew Resource Management (CRM)
training is a method of applied human
factors training that aims to provide
operational personnel with the knowledge,
skills and attitudes to manage themselves
and available resources more safely and
effectively
IATA Training & Development Institute
Brief history of CRM
TCVT-05 Human Factors in Aviation
Two years after Tenerife accident the NASA held a
workshop covering the topic “Resource
Management on the Flight Deck”
Many accidents had shown that the main cause of
them was not the ability of the crew to manoeuvre
the aircraft
Other issues appeared like:
7
Deficiencies in information processing
Judgement and decision making
Crew cooperation
Leadership and authority culture
IATA Training & Development Institute
The business school approach to HF
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Some key accident reports and research studies
used the expression “resources management” to
encompass the sort of “non technical skills” needed
by pilots, whose training had been predominantly
technical
So NASA, FAA and some airlines started using the
acronym CRM initially for “cockpit resource
management” and later cockpit changed to crew
The first consultant developing a CRM training
applied business schools techniques and approach,
introducing the “management role” in the cockpit
IATA Training & Development Institute
CRM evolution
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TCVT-05 Human Factors in Aviation
CRM was an application of Human Factors to pilots
training, so became predominantly a “flight
operations” issue related to pilots
Relevant regulations evolved under the ICAO Annex
6 “Operations of Aircraft” focus, like was the case of
FAR/CFR Part 121 and 135 in the US, and JAROPS and now EASA Implementing Rules Part OPS
Still today CRM is considered an Operations matter,
although some extensions of CRM are applied to
ground and maintenance staff, and also to Cabin
Crew
IATA Training & Development Institute
General CRM requirements
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TCVT-05 Human Factors in Aviation
Initial CRM training
Operator specific CRM training
Aircraft Type specific CRM training as part of
operator´s conversion training
CRM training for new operative role, either as
Captain for pilots or Supervisor for Cabin Crew
Recurrent CRM training scheduled to cover the
content of the initial syllabus over a three year
period
IATA Training & Development Institute
Additional requirements
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TCVT-05 Human Factors in Aviation
There are also requirements for CRM facilitators,
and also for flight instructors
CRM skills have to be assessed on continual
basis in training and checking, using a standard
called NOTECHS (for Non Technical Skills
assessment)
CRM (HF) elements should be introduced in all
training design and delivery
IATA Training & Development Institute
CRM TRM
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CRM began in the aviation industry in the late 1970s
following a string of serious aviation accidents
precipitated by the ineffective management of
available resources
The philosophy and training approach used in CRM
has since become the accepted model for
developing applied human factors skills amongst
front-line operators in many high-risk industries
CRM / TRM proved a good method to improve team
performance and safety in many other activities
IATA Training & Development Institute
CRM Training
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CRM training has been defined as a set of
instructional strategies designed to improve
teamwork in the cockpit by applying well tested
training tools and appropriate training methods
With specific content like:
Teamwork knowledge
Skills
Attitudes
Communication
Leaderships
IATA Training & Development Institute
The purpose of CRM
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CRM training is about teamwork, closed-loop
communication and decision-making in context
CRM training is a team training strategy
Training is about the diagnosis, remediation, and
improvement of required competencies
The ultimate goal is to improve crew
performance and avoid human errors
IATA Training & Development Institute
How CRM originated
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Crew Resource Management (CRM) training is
a form of applied human factors training that
aims to provide operational personnel with the
knowledge, skills and attitudes to manage
themselves and available resources more safely
and effectively
CRM began in the aviation industry in the late
1970s following a string of serious aviation
accidents precipitated by the ineffective
management of available resources.
IATA Training & Development Institute
CRM extension TRM
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TCVT-05 Human Factors in Aviation
The philosophy and training approach used in
CRM has since become the accepted model for
developing applied human factors skills amongst
front-line operators in many high-risk Industries
From flight deck to cabin crew, maintenance,
flight dispatchers, ATCO, ANS, medicine,
ground transportation, marine transportation,
nuclear power, etc.
IATA Training & Development Institute
The Extension of CRM
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TCVT-05 Human Factors in Aviation
Crew Resource Management (CRM) on the
flight deck gained much of its impetus from the
fact that there had been a number of serious
incidents and accidents in which poor
communication, crew performance and
inadequate behaviour were seen as significant
contributory, if not causal, factors
We call that now TRM or Team Resource
Management
IATA Training & Development Institute
TRM view
TCVT-05 Human Factors in Aviation
TRM is a philosophy which helps us realize
that we humans are error prone; a
philosophy which will help us put in place
more and better safety nets; a philosophy
which will help each one of us play a better
and more constructive part in our own team
and the larger aviation team of which we are
part."
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IAA – Irish Aviation Authority
IATA Training & Development Institute
What is it?
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TCVT-05 Human Factors in Aviation
TRM objectives are defined as: Strategies for the best
use of all available resources - people, equipment and
information to optimize the safety and efficiency of Air
Traffic Services operations
TRM is a safety management intervention that protects
ATM systems from a common cause of system failure
The main objective of TRM is to reduce or minimize the
impact of teamwork related errors within the ATM system
IATA Training & Development Institute
Development of TRM for ATM
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TCVT-05 Human Factors in Aviation
Joint development by operational staff and human
factors experts
Linked to human factors incident and accident
investigations
The operational staff know their working
environment in detail, and where the safety
weaknesses exist
Methods based on best practice from airline Crew
Resource Management CRM
IATA Training & Development Institute
The Benefits of TRM
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TCVT-05 Human Factors in Aviation
Reduced teamwork-related incidents
Enhanced task efficiency
Improved use of staff resources
Enhanced continuity and stability of teamwork in
ATM
Enhanced sense of working as a part of a larger
and more efficient team
Increased job satisfaction
IATA Training & Development Institute
Team Performance
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Understanding the nature of roles in the teams;
Good communication among team members
Staying aware of own situation as well as the
situation of others
Understanding decision-making strategies and
individual differences within them
Appreciating different controlling styles which
both leaders and followers can support
Recognizing own as well as others’ stressors
IATA Training & Development Institute
TRM Training Content
23
Team work
Team Roles
Leadership
Error management
Communication
Situational Awareness
Decision-making
Stress management
Impact of new automation
IATA Training & Development Institute
TRM and Management
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TRM is used now not only for safety, but also for
the improvement of efficiency in operations
Its application leads to greater task efficiency
and improved use of staff resources
It is difficult to evaluate the benefits to be gained
from the implementation of enhanced team
training except perhaps to compare it with the
potential cost, in human and monetary terms, of
an incident or accident brought about by poor
teamwork
IATA Training & Development Institute
TRM Place in the Organization
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Considering that TRM is not a regulatory
requirement it should not be viewed as a
cosmetic and expensive "add-on” to existing
training, but rather as an integral part of the
training structure and culture within the
organisation
It started as a “soft skill training” or non technical
skill training
Now is part of staff competence and good
business practice
IATA Training & Development Institute
26
Leadership
Task management
Teamwork
Communication
Risk management
Situational awareness
Decision making
Emergency management
Self management
TRM Competency Elements
1.
2.
3.
4.
5.
6.
7.
8.
9.
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Leadership
IATA Training & Development Institute
Task management
IATA Training & Development Institute
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Teamwork
IATA Training & Development Institute
Communication
IATA Training & Development Institute
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Risk management
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32
Situational awareness
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Decision making
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34
Emergency management
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Self management
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Communication
35
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Interpersonal communication is a key element in
Human Factors and in Teamwork
In the SHEL Model of Human Factors there is a
fundamental interface: L L (Liveware to Liveware)
The full issue of Communication from a theoretical
point of view exceeds this course scope
We will focus now our attention to interpersonal
communication process and skills in a restricted way
IATA Training & Development Institute
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I know you believe you
understood what you
think I said, but I’m not
sure you realize that
what you heard is not
what I meant to say...
Anonymous
Less Clear than it Seems
IATA Training & Development Institute
Communication Basics
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Human communication has two
characteristics:
You are communicating all the time, in your
words, tone of voice, actions, dress, your
presence and even your absence
You cannot not communicate
Communication is a process of negotiating
meanings
IATA Training & Development Institute
Remember Mental Models?
39
Communication is
affected at both ends by:
Expectations
Attitudes
Prejudices
History
Values
Beliefs
Emotions
Stress
Etc.
IATA Training & Development Institute
The Communication Process
DECODING
UNDERSTANDING
TCVT-05 Human Factors in Aviation
MESSAGE
SYMBOLS
RECEIVER
FEEDBACK
IDEA
CODING
CHANNEL
CONTEXT / ENVIRONMENT
40
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SENDER
IATA Training & Development Institute
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Noise altering signal (message distortion)
Encoding errors or bias
Decoding errors or bias
No feedback
Context influences
IATA Training & Development Institute
Examples of communication processes
Human Thought (idea) Speech generation Sound generation
Auditory perception Speech perception
Visual scene Video representation/camera Radio propagation
Video representation display Visual perception
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TCVT-05 Human Factors in Aviation
Visual Perception as an image Verbalization Speech Sound emission Reception Getting the message Re
creation of some image
IATA Training & Development Institute
Types of Communication
Face to Face Verbal
Body language (postures,
gestures, dress, eye contact)
Voice tonality
Words (contents and
meaning)
43
Non Verbal
Visual, iconic, symbolic
Written
Composite multimedia
IATA Training & Development Institute
Interferences or “noise”
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Environmental noise
Physiological impairment
Semantic (interpretation of the meaning of
certain words or expressions)
Syntactical (Grammar mistakes, misspelling)
Organizational (Idea structuring)
Cultural (Stereotypical assumptions)
Psychological (all cognitive filters and biases)
IATA Training & Development Institute
Human Interaction
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TCVT-05 Human Factors in Aviation
Since the attention resources are limited
(Wickens) communication is enabled by a simple
motivation: interest
One basic communication skill is to develop a
“broadband” attention channel and the
necessary flexibility to switch quickly between
sources and messages
IATA Training & Development Institute
Levels in Communication
Human interaction takes place at two levels:
Level One is for Information exchange giving and
receiving
Level Two is giving meaning at the information we are
receiving
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The process of giving meaning is like
“understanding” “making sense” or “interpreting”
according to our own mental information process
This level is cognitive and emotional at the same
time
IATA Training & Development Institute
Why communication is so important?
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All organization´s work and processes are based
on communication (information transfer)
This is one case when humans perform worst
than technology, due to human variability
In risk industries like Aviation, poor
communication is always a source of hazards
and risks and a factor in occurrences and
inefficiencies
Communication is a necessary skill in any
educated activity and business process
IATA Training & Development Institute
Communication and Safety
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Communication failure is very often cited as root
cause or factor in occurrences and accidents
It is clear that changing a single factor like
communication cannot overcome the multiple
threats to safety in complex organizations like ours
Aviation communication is critical specially in the
flight operations environment, flight deck, OCC,
ATM-ATC (Active Environment) but also in the
backstage, as a latent factor in maintenance, ground
operations and in general management
It should be always considered in risk assessment
as a main factor
IATA Training & Development Institute
Some problems with CRM
CRM Instructors / Facilitators requirement: to be
acceptable to the Authority (wide range of
interpretation)
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TCVT-05 Human Factors in Aviation
Some countries have adopted a system for approval
of CRM instructors via Examiners
Section 2 of old JAR-OPS (AMC) however provided
guidance for CRM instructors competency
requirements
IATA Training & Development Institute
CRM misconceptions
50
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Evaluation and follow-up of CRM training not
fully provided by NOTECHS implementation
All problems and criticisms on CRM arise of the
initial nature of HF training for pilots, added as a
“backpack” or “add-in” to pilots’ training and
checking
IATA Training & Development Institute
Significant CRM accidents
BEA Flight 548 Trident, Staines (London) June 1972
Eastern Air Lines Flight 401 Tristar, Everglades FLA
December 1972
PANAM-KLM collision on Tenerife, March 1977
United Airlines Flight 173 DC-8, Portland Airport on
December 1978
Almost 80% of large airliners accident reports
mention CRM as a contributing factor
IATA Training & Development Institute
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NASA/UT FAA Aerospace Crew Research Project (March 1995)
IATA Training & Development Institute
Thank you
Human Factors and Individuals
Session 9
Let´s talk about people at work
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Skills, in their most general sense, can be
viewed as the trained abilities of people
(including management and leadership abilities,
technical, scientific and production abilities, and
soft/ interpersonal abilities) for which there is a
demand within the formal economy
IATA Training & Development Institute
Competencies
SKATE
Skills
Knowledge
Attitude
Training
Experience
IATA Training & Development Institute
3
KSA
Knowledge domain
Psychomotor domain
Affective doman
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New Skills or Skills for Innovation
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People also acquire skills that assist them in
developing novel products or in organizing work
and production processes in new ways
This is the case in technological industries and
in high risk industries, where change is a current
order
We also need new skills when reshaping the
industry for economical reasons or developing
new ways of doing old things
IATA Training & Development Institute
Other Meanings of Skills
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“An ability or proficiency at a task that is
normally acquired through education, training
and/or experience”
The term ‘skill’ is sometimes used synonymously
with related concepts of ‘competence’,
‘expertise’, ‘knowledge’ or ‘human capital’
We can have different level of skills and different
types of skills
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
Aviation Employee Competencies
6
Safety orientation and understanding
Customer service orientation
Flexibility and adaptability
Communication Skills
Teamwork
Cultural Sensitivity
Integrity and High Ethical Standards
Dependability
Mindfulness
Professionalism
IATA Training & Development Institute
Levels of Skills
Skills definitions are used for teaching and learning,
and for training design
Job profiles and definitions are also designed upon
skills
We normally define competencies as a KSA set:
KNOWLEDGE
SKILLS
ATTITUDES
Competencies can be:
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TCVT-05 Human Factors in Aviation
Functional (Technical)
Personal (Non Technical, personal attributes and values)
IATA Training & Development Institute
Individuals Vs. Organizations
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Current research and focus on Human Factors and
accidents is extending from individuals to
organizations; from the sharp end to the
Management and Organization (Reason’s Model of
Organizational Accidents)
However, the human factors case and the safety
case is not a binary issue A or B
This is rather a complex issue where humans are
everywhere, doing, organizing, supervising, making
plans or designs in the whole system
The same issue of cognition appears to any human
making decision at any level
IATA Training & Development Institute
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TCVT-05 Human Factors in Aviation
The many forms of the Swiss Cheese
IATA Training & Development Institute
The Call on Culture and the people
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TCVT-05 Human Factors in Aviation
New Safety Management Systems in Aviation
are making a call on the safety culture
Safety focus is also on performance, and
organization performance and human
performance are connected more than often
So we have to look at individuals not as “factors”
but as people
Human Capital Human Resources Human
Factors
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People interacting on People
IATA Training & Development Institute
TCVT-05 Human Factors in Aviation
Another Focus of Human Factors
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TCVT-05 Human Factors in Aviation
We´ve been talking about HF and Organizations
Human Factors have a special relevance for
individuals in high risk organizations
We usually have defined competences profiles for
Managers and for very specialized technical staff
like pilots and ATCO’s
Under the new knowledge of Human Factors we
need to review competence profiling for all aviation
personnel
Taking into account the relevance of any staff for
risks and safety
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Example on Core Competencies
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TCVT-05 Human Factors in Aviation
Managing uncertainty and ambiguity; related to
dynamic operational risk assessment
Agency and Responsibility: any staff should be
able to take responsibility and know what this
means to act as an effective agent at job. Know
the consequences of the acts.
Follow process steps, prescribed procedures
and best practices. Understand the limitation of
procedures, the general nature and orientation
of processes, and clear picture of the goals
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Core Competencies -2-
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TCVT-05 Human Factors in Aviation
Managing Emotion: getting away of the idea that
emotion and reason are separate, or emotion is an
accepted personality trait. Understanding emotions
and relationship with effective leadership, stress and
performance
Teamwork: every staff in aviation should be able to
work in a teams, understand teambuilding and
interact efficiently in teams, solving conflicts and
keeping the goal
Understanding Technology
Managing Change
Learning Competencies
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Competence Management
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TCVT-05 Human Factors in Aviation
You need a good initial profiling made by
professionals and apply in selection processes using
the right and validated tools
You need to understand competence management
and make the supervision and follow up having this
in scope
Training Design, Training Needs Analysis
Cultural factors: develop sense of belonging to the
organization, stimulate professionalism. Motivate for
commitment and continuous learning and
improvement
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Individual Strong Set of Values
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TCVT-05 Human Factors in Aviation
Employees in any aviation organization should
understand the duty of care and responsibilities
towards the public: passengers, users,
customers
Implication in safety
Understanding the core values of safety and
accident prevention
Development of Airmanship and Professionalism
Mentoring role of any manager and supervisor
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Professionalism
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TCVT-05 Human Factors in Aviation
Professionalism in aviation is a big current topic of
discussion since the NTSB and FAA have held a
three-day forum on the topic to look at developing
and ensuring pilot and air traffic controller
excellence
According to FAA and NTSB heads, there is a very
simple equation: professionalism on the flight deck
and in the ATC leads to greater safety.
We should extend this equation to all involved at
MRO, Airports, and operators, including KDM
Professionalism is not restricted to “license holders”
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Professionalism and Human Factors
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TCVT-05 Human Factors in Aviation
After Colgan Air accident at Buffalo Airport in 2009,
both FAA and NTSB initiated a Call to Action to look
at safety issues including human factors, pilot
training and professionalism
There incidents and non reported occurrences, like
overpass airport destination by 150 miles without a
word after a long radio silence; landing at wrong
airport; and similar, that cannot be explained only as
“human errors”
Professionalism is related to culture, education,
training, human capital, and obviously to
Management
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The USA Approach
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TCVT-05 Human Factors in Aviation
Screening and Selection of Pilots
Structured development of Professional pilots
Excellence in ATC and Maintenance
Developing Professionalism and Excellence by
training
Shared responsibility Operator/Individual
The Captains’ role in ensuring professionalism
The role of the Regulator in developing
professionalism in aviation
The role of Instructors/Schools in developing
professional cultures
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FAA Professionalism Checklist for
Pilots
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TCVT-05 Human Factors in Aviation
Do you always report for duty rested and prepared?
Are you continuously refreshing your knowledge?
Are you rigorously following checklists and proscribed procedures?
Do you discipline yourself to stay at least 10 minutes ahead of the
aircraft?
Do you use quiet moments in the cockpit productively (i.e., to
recheck the flight management system or flight plan)?
Do you thoroughly brief and communicate with everybody, including
other crewmembers and air traffic control?
Do you fly with precision, even when you are by yourself?
Do you always push for a higher standard of professional flying?
What do you expect from other pilots? Do you not let a moment for
teaching or mentoring pass?
Do you solicit and give honest feedback?
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How to get strong professionals?
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TCVT-05 Human Factors in Aviation
If business is about getting things done by
people
Is this professionalism issue related to pilots
only?
To flight operations?
Or is a company HUGE problem related with
HRM and Human Capital Strategies?
Where is the boundary between Corporate
and Individuals (employees) responsibility?
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Non-technical skills
Problem solving
Initiative
Creativity
Interpersonal Skills
Business Awareness
Adaptability
Teamwork
Innovation
Technical skills
Time Management
Communication
Leadership
Teams and Individuals
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TCVT-05 Human Factors in Aviation
All organization´s work is based upon teams and
individuals: the integrating of people and work
processes
Key players in work organization are all managers
and supervisors, team leaders responsible for
integrating teams into a coherent WHOLE
The whole issue only works if we have adequate
skills matching in well designed work processes
Individuals characteristics can be influenced by
training, coaching and motivating the right people
We have to do this also through the corporate
culture
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Group Discussion
Human Factors at individuals level
Hard Skills and Soft Skill integration
Competence Management
TCVT-05 Human Factors in Aviation
Profiling job design
Selection and recruitment
Training (TNA, Training Design, Safety Case)
Supervision and system feedback
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QMS and SMS Human Factors
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TCVT-05 Human Factors in Aviation
TCVT-05 Human Factors in Aviation
Thank you