Safety Stand Down 2013 Building a Safety Community

Presented to: T BAA By: Tampa FAASTeamDate: April 17, 2013

Federal AviationAdministration

• Federal Aviation• AdministrationSafety Stand Down

2013

Building a Safety Community

Safety Stand Down 2013April 17, 2013


Agenda0745 – 0845 Breakfast0845 - 0950 Welcome and Introductions0950 - 1000 Break1000 – 1050 Human Factors

Dr. Karen D. Dunbar 1050 – 1100 Break1100 – 1200 Loss of Control

Dennis H. Whitley1200 – 1245 Lunch1245 – 1300 Tribute To Flight Attendants1300 – 1445 Miracle on the Hudson

Doreen Welsh1445 – Closing remarks - Adjourn

2



Welcome

• Exits• Restrooms• Emergency Evacuation• Breaks • Sponsor Acknowledgment• Other information

3



Sponsors

Altra MedicalDJ Public Relations Inc.ExecuJet Charter ServiceFederal Aviation AdministrationFederal Aviation Administration Safety TeamHillsborough County Aviation AuthorityJETEX Flight Support

4



Sponsors

NBAAOSI Restaurant Partners LLCRockwell CollinsSt. Petersburg - Clearwater Int. AirportStandard AeroSignature Flight Support

5



Sponsors

Landmark AviationTampa Air Traffic Controllers Tampa International Airport Fire DepartmentTampa Jet CenterWest Star AviationWINSLOW Life RaftWorld Fuel

6



Tampa FSDO Personnel• Amanda Cromie

– FSDO Manager• Jose Figueroa

– Front Line Manager• Patrick Seggerman

– Front Line Manager• James Minary

– FAASTeam Program Manager

7



Florida FSDO Borders

• Alabama FSDO SO09

• North Florida FSDO

• SO15 & SO35 • South

Florida FSDO SO19



• North Florida

FSDO SO35

Florida FSDO Borders

Tampa FSDO SO35

Orlando FSDO SO15



FSDO Information– CFI and DPE Oversight– Flight Schools– Charter Companies– Film Production– Accidents & Incidents– Complaints– Repair Stations – Mechanic Schools– IA Mechanics – Special Flight Permits– Field Approvals

10



Contact us

• http://faa.gov• Field & Regional Offices• Flight Standards District Offices (FSDO)• Select State• Select Office

11

http://faa.gov/



Wings Credits• 3 Knowledge Credits for this Stand Down

– Preregistered?• Initial roster

– Not Preregistered?• Sign in with legible faasafety.gov email

• No Account?– See a Rep today

12


Federal AviationAdministration 13

1



The Safety Stand Down

• Military Origins– Response to Safety Issue– Temporary Operations Halt– Devote time to Safety

14



The Safety Stand Down• Human Factors

– Investigates interaction between humans and systems– Evaluates fit between user, equipment and environment– Considers capabilities and limitations – Focus on task, demands, equipment and information

• Loss of Control– Number 1 Factor in fatal accidents

• Appch. & Ldg. LOC Workgroup– Findings & Recommendations

» Technology» Human Factors

15



LOC Workgroup Findings

• Lack of single – pilot CRM skills• Unstabilized approaches• Flight after extended periods of not flying• Inappropriate go-around procedures• Insufficient transition training• Over reliance on automation• Flight after use of drugs• Lack of Aeronautical Decision Making Skills

16



FAA Information Session• Presented by:

– FAA Southern Region– Tampa Florida FAASTeam

17



Introduction to Human Error

• Presented by:Dr. Karen D. DunbarFAA Safety TeamRepresentative

18

Federal AviationAdministrationHuman Error

Making Sense of Accident Reports

Presented to:

FAASTeam 2013 Safety Stand Down

19



Overview

• Error Fundamentals• System aspects of error• Application of Error Fundamentals

• Gold Seal Key Concepts

SSD 2013

20



A. Human

B. Universal

C. Inevitable

D. A bad thing

To Err is:

21



In so far as I am able, I agree to suspend thoughts of judgment and retribution with respect to the characters in the stories I am about to hear or relate; and to the presenter of this seminar. I will seek to understand why events occur rather than to identify and punish those

Certificate of Agreement Safety Stand Down 2013

SSD 2013

who were responsible for those occurrences. I understand that this agreement has no legal effect whatever and, in any case, applies only during this seminar unless I choose to continue with this way of thinking in the future.

22



The 5 Ws

WhoWhatWhenWhereWhy

23



The 6th W

WhoWhatWhenWhereWhyWhat’s to be done about it?

24



Four questions are easy

WhoWhatWhenWhereWhyWhat’s to be done about it?

25



The Accident Report

WhoWhatWhenWhereProbable CauseSafety Recommendation

26



The Accident Report

WhoWhatWhenWhereMoose on FieldMoose proof fence

27



Hindsight BiasHindsight

OutsideViolation

BreakdownLost the Bubble

FailureError

Bad Judgment

Incident EvolutionTime(Sidney Dekker 2006)

28



Incident EvolutionTime

Inside

-Easy-Profitable

-Loyalty

-Prod-uctive

-Flexible

-CommonSense-Better -Skill

-Creative-Perfect

-Good Idea-Judgment

-Experience

-BestOption-Quick

(Sidney Dekker 2006)

Hindsight Bias

29

SSD 2013



Ever have one of those days?

• Take a wrong turn on a familiar route

• Set out for work when you intended to go to the store

• Lock keys in car or house

• Can’t find the keys to lock in car or house

30



People cannot easily avoid those actions they did not intend to commit

James Reason & Alan Hobbs (2003)

SSD 2013

31





Blaming people for their errors is emotionally satisfying but remedially useless.

We’re still accountable for our mistakes though.

32



Mikey’s story• Late night with interrupted sleep• Altered routine• Preoccupation with work

• How big an error?– Consequence was huge– Error was common

33




SSD 2013

We all operate within systems

Sometimes without knowing it

34



Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia

Deaths

35




Deaths

36




Deaths

38

37



Accident Chain of Events

38



Accident Chain of Events

39



Accident Chain

Unsafe Acts

Preconditions

Cultural Influences

40



Unsafe Acts

Cultural Influences

Preconditions

Leaving Mikey in car

41



Pre-conditions

Cultural Influences

Pax side airbag

Fatigue

Warm Weather

Preoccupation Leaving Mikey in car

Sleeping Child

42



Cultural Influences

Child care responsibilityWork ethicPax side airbag

Fatigue

Sleeping Child

Warm Weather

Preoccupation Leaving Mikey in car

43



Child care responsibilityWork ethicPax side airbag

Fatigue

Warm Weather

Preoccupation

Safety significant errors can occur at all levels of the system

Leaving Mikey in car

Sleeping Child

44



The Swamp

Unsafe Acts

Preconditions

Cultural Influences

Adapted from Reason (1990)

45



Adapted from Reason (1990)

Coming Soon Bayou Junction

Housing Development

Unsafe Acts

Preconditions

Cultural Influences

46



People

Structure/Organization

Technology

Tasks

The General Aviation System

47



200

01950

196

0 197

0 198

0 199

0

U.S. General AviationSource NTSB

0

10

20

30

40

50

60A

ccid

ents

/100

,000

flig

ht h

ours

Accidents=Approximately 7/100,000hrsFatal Accidents=Approximately

2/100,000hrs

48



Human Error is Both Universal and Inevitable

It is the Downside of Having a Brain


SSD 2013

49



A Simplified “Blueprint” of Mental Functioning

Input Functions

Senses

Feedback Loops

Filter (Attention)

Conscious Workspace

Long-term memory(Knowledge base)

Output Functions

Hands, Feet, etc.


50



Conscious Workspace Long-term Memory

General Problem SolverLimited CapacityContents AvailableSequential ProcessingSlow and LaboriousEssential for new Tasks

Vast Collection of ProgramsNo Limits to Size or DurationUnconsciousParallel ProcessingRapid and EffortlessHandles Familiar Routines and Habits


Trial and Error Programming

51



A

CBCB

A

Conscious Work Space

52



Long-term Memory

2 + 2 = …..knock knock “...................?”Mary had ..................The sky is ……..Grass is …..

53



Lnog-trem Meromy porgarms rley haevly on vsuisaul ifnoramiton and ptatren rcoegiontin hbaets.

Plitos are paticrculry aedpt at ptatren rcoegiontin and ulusaly taht wokrs wlel for tehm but oaccsillony taht hmaun tenendcy cuseas prelombs.

Rnunnig a falmialr porgarm in rospense to a difefernt stitauion or rnunnig a corrcet porgarm ipormprely can rsuelt in dsisater.

We are creatures of hbaet

54

SSD 2013



Count the F’s

FINISHED FILES ARE THE RESULT

OF YEARS OF SCIENTIFIC

STUDY COMBINED WITH THE

EXPERIENCE OF MANY YEARS

55



Count the F’s





56

3?



Count the F’s





57

3 or 6?



Choice Point needing conscious attention

New Path

Wrong Path Taken

Usual Onward Path

Skill-based Slip

Highly Routine Sequence

58



Directly to Work

Mikey’s story

Turned left at Pereira Drive He should have turned

right at Pereira

Day Care Then work

His office's parking lot at the Department of

EducationFrom: Home

To: Work

59



People cannot easily avoid those actions they did not intend to commit…

SSD 2013

but they can gain a better understanding of when they’re likely to err.

60



Error/Environment Logging

Log errors by date

Describe environment

Include health, fatigue, stress

Look for patterns

61



StressWalking the line

$

6 In.

8 In. 20 Ft.

62



StressWalking the line

63



Extreme Stress Makes You StupidPe

rfor

man

ce

Increasing Stress

Perf

orm

ance

Increasing Stress

64



Managing the Managable

2 hour flight @ 10 gph. = 20 gal.

+ 1 hour reserve = 30 gal.

Fuel on board = 25 gal.

65



Managing the Managable

Call for fuel & top off

Enough fuel for the return tripJust enough time to make the luauLaunch with the fuel you haveAmple time before meetingMust fuel before returnConsider ditching evil partner

66



A. What?

B. Why?

C. When?

D. What’s to be done about it?

The Ws that are hardest to answer are:

67



A. PCs but not MACs

B. Conscious Workspace

C. Long Term Memory

D. MACs but not PCs

Programming is an attribute of:

68



A. NTSB & FAA Investigations

B. Central Nervous System

C. Long Term Memory

D. Conscious Workspace

“Trial and Error” is an attribute of:

69



Winners never quit ……

Quitters never….

Plan the flight & ……

You’ll never get anywhere if you don’t have a ….

When in doubt; stick to the ……

70



Get-there-itus

Plan Continuation Bias“The continuation of an original plan even with the availability of information that suggests that the plan should be abandoned.”

71



If the flight’s not conforming to the plan …..

It doesn’t pay to wait for things to get better.Address small problems earlyBefore they become big ones

SSD 2013

72



Errors are not intrinsically bad

We are “hardwired” to make errors

Bad News Good News


73



The Recipe for Disaster

Human Error + Unforgiving Activity= Disaster

74





You cannot change the human condition,

What’s to be done about it?

but you can change the conditions in which humans work. (and play)

75



How many people?

76



or this one ….. ?

77



583 fatalities – 64 survivorsTenerife 27 March 1977

The Best People Tend to Make the Worst Mistakes

SSD 2013

78




Many Errors Fall into Recurrent Patterns

79



One More Thing

•Confirmation Bias

80



One More Thing

Confirmation Bias

You

Common-sense Consistent Capable CorrectCoherent Clever

Other Drivers

Ignorant IneptIdiot IncompetentImpolite Ill-mannered

Fundamental Attribution BiasJames Reason & Alan Hobbs (2003)

81




• James Reason & Alan Hobbs (2003)

SSD 2013

You can’t understand why accidents happen if you assume the pilots involved were idiots.

82



A. Confirmation?

B. Hindsight?

C. Plan Continuation?

D. Fundamental Attribution?

The human biases that may negatively influence accident investigations are:

83



A. Anti-authority attitude

B. Sense of invulnerability

C. Past record of performance

D. Confirmation Bias

The best people make the worst mistakes because of their:

84



A. The Preconditions level

B. The Unsafe Acts level

C. All levels

D. Cultural Influences level

Safety-significant errors can occur at _______ of the system:

85



A. Should be avoided

B. Improve performance

C. Inhibit performance

D. Require medication

Moderate stress levels:

86



A. Lowest - Highest

B. Highest - Lowest

C. Lowest - Appropriate

D. Appropriate - Highest

Effective interventions should target the _______ level, but are usually most effective at the _____ level of a system.

87



Reading List• Managing Maintenance Error

– James Reason and Alan Hobbs• Set Phasers on Stun and The Atomic Chef

– Steven Casey• Understanding Human Error

– Sidney Dekker• Deep Survival

– Laurence Gonzales• The Limits of Expertise

– Key Dismukes• Sway

– Brafman & Brafman

88



Up next:

89



Up next:

90

Loss of Control



Up next:

91

Let’s take a little break

Loss of Control



Loss of Control Panel

92

Moderated by:Dennis H. WhitleyFAA Safety TeamLead Representative



Loss of Control Panelists• Mr. Jack Tunstill

– CFII St. Petersburg• Mr. Mike Windiman

– CFII Plant City

93



Fatal LOC Accidents 2001-2010

94

Man

euve

ring

App

roac

h

En

rout

e

Init.

Clim

b

Unk

now

n

Take

Off

Unc

ontro

lled

Des

cent

Land

ing

Em

er. D

esce

nt

Em

er. L

andi

ng

Em

er. A

fter T

.O.

LOC Accidents 10-Year Period

0

50

100

150

200

250

300

350



The PAVE Checklist

• Pilot• Aircraft• enVironment• External Pressure (s)

95



LOC Panel Case Study Number 1

96

• Pilot– Private Pilot– Total Time ……319– Time in type …. 1

• Aircraft– Jodel D-9




97

• enVironment– General Dewitt Spain, TN (M01)– Runway 16/34 225 MSL 3,800 x 75’– Left Base to Final Runway 34 – Weather (MEM – 11 nm SSE)

• VFR Few @ 7,000/10 SM• Wind Variable @ 3

http://skyvector.com/?ll=35.200694444,-90.053972222&chart=115&zoom=3



Discussion

98




99

• Pilot– Private Pilot– Total Time ……604– Time in type ….248

• Aircraft– Cirrus SR 22




100

• enVironment– Aero Plantation, NC (NC21)– Runway 6/24 634 MSL 2400 x 60’– Left Base to Final Runway 6 – Weather (EQY – 6.5 nm East)

• Wind 320@11, Gust 22



310@11, G22




102

• Parachute– Deployed, but not fully

extracted.

• Autopsy Findings– Diphenhydramine– Pseudoephedrine– Zolpidem



Discussion

103




104

• Pilot– Private Pilot– Total Time ……975– Time in type ….44

• Aircraft– TBM 700




105

• enVironment– Cobb County Field, GA (KRYY)– Runway 9/27 1078 MSL 6311x100’– Final Approach to Runway 9 – Weather

• 5,500 BKN, 10 SM• Wind 120@6






107

• Autopsy Findings– Alfuzosin

• Prostate – Bisoprolol *

• Beta blocker– Quinine

• Arthritis– Tramadol

• For moderate to severe pain

* Known to AME



Discussion

108



Dedication

Niel Armstrong 1930 - 2012

109



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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Safety Stand Down 2013 Building a Safety Community

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