Beyond Pilot Error: Aviation Safety and Training Kathy H Abbott, PhD, FRAeS Federal Aviation Administration Capt. John M. Cox, FRAeS Safety Operating Systems 27 April 2010 Federal Aviation Administration Pilots Are Unique People Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 2 Human Error and Aviation Safety Old View • Human error is the cause of accidents • Human is the most unreliable component • Improve safety by restricting human action New View • Human error is the effect of deeper issues • Human is necessary to create safety • Improve safety by understanding (and leveraging) human performance From Dekker 2002 Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 3 Risk Mitigation – Where? Flexibility/ Adaptability Design Engineer Envelope Protection Cat III Autoland Designer Error TCAS/ ACAS Flight Director Pilot Circling Approaches Pilot Error Overview • Flight Path Management and Flight Deck Automation – where can training be improved? • WHY do errors occur? • Looking beyond error at the “sharp end” Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 5 Flight Path Management and Flight Deck Automation – where can training be improved? • Performance-based Operations Aviation Rulemaking Committee (PARC) and Commercial Aviation Safety Team (CAST) PARC/CAST (preliminary results) • FAA International Rudder Survey • Recent accidents/incidents Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 6 Flight Deck Automation Working Group • Joint under the Performance-based Operations Aviation Rulemaking Committee (PARC) and Commercial Aviation Safety Team (CAST) • Current design, training and use of flight path management systems in transport airplanes in “121-like” operations • Preliminary results from: – 734 incidents from Aviation Safety Reporting System (ASRS) within scope – 46 major incidents and accident reports within scope – normal ops via Line Operations Safety Audit (LOSA) Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 7 Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 8 X X X X X X Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 X Federal Aviation Administration 9 Potential Areas for Improved Pilot Training • Manual handling • Flight path management systems • Unusual attitude avoidance, recognition and recovery • Speed and energy management • Use of rudder • Managing malfunctions • Managing distractions • Crew coordination and communication Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 10 Turkish Airlines Flight TK 1951 Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 11 Legal Regulatory Organization Equipment design, training, procedures Pilot Accident Adapted from Reason Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 12 Legal Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 13 Regulatory Organization Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 15 Equipment Design Training Procedures Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 16 Pilot Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 17 Legal Regulatory Organization Equipment design, training, procedures Pilot Data Collection? Investigations? Training? Accident Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 18 Operators, Regulators, Manufacturers, Training Organizations… It is about training all the people Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 19 Human Error and Aviation Safety Old View • Human error is the cause of accidents • Human is the most unreliable component • Improve safety by restricting human action Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 New View Revised • Human error is the effect of deeper issues • Human is necessary to create safety • Get away from blame and ask “why”? • Improve safety by understanding (and leveraging) human and organizational performance Federal Aviation Administration 20 Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Federal Aviation Administration 21