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