Considerations In The Investigation Federal Aviation Of Incidents - ICAO

Considerations in the Investigationof Incidents:Human Factors of ATS IncidentsPresented to: Air Traffic Incident Analysis WorkshopBy: Andrew Johnson & Lenard CarterFAA ATO Safety and Technical TrainingDate:20 July 2016Federal AviationAdministration

ATS Incident Analysis GroupWorkshopJuly 2016ATS Incident Analysis GroupFederal AviationAdministration

Human Factors Human error underlies most aviation accidents and incidents The focus of most accident/incident investigations are:o Human erroro Introduced riskso Contributing factorso Breakdowns in crew resource management (CRM) Human factors involves gathering information about: human abilities human limitations other characteristicsATSAnalysisGroup Workshop: ATSIntegratedSafetyTraining3 IncidentIncidentAnalysisGroup Human FactorsFederal AviationAdministration

Human Factors cont. In the aviation industry, the science of human factors isdedicated to better understanding how humans can mostsafely and efficiently be integrated with technology. We will focus on understanding human abilities and limitationsATSAnalysisGroup Workshop: ATSIntegratedSafetyTraining4 IncidentIncidentAnalysisGroup Human FactorsFederal AviationAdministration

Human FactorsATS Incident Analysis GroupATS Incident Analysis GroupFederal AviationAdministration

INTRODUCTIONThe purpose of thistopic is to understandhow humans processinformation to makedecisions and to learnabout human errorsand at-risk Group IntegratedSafetyTrainingWorkshop: Human Factors6 ATSFederal AviationAdministration

OBJECTIVES Identify reasons for humanerrors Discuss the difference betweeninternal and external factors Discuss the difference betweenerrors and at-risk roup IntegratedSafetyTrainingWorkshop: Human Factors7 ATSFederal AviationAdministration

INTRODUCTION TOHUMAN ERRORATS Incident Analysis GroupFederal AviationAdministration

RECAP AND INTRODUCTION TO HUMAN ERRORThere are 3 types of Human Error:MISTAKEYou don’t know what you need to know.LAPSESomething you forgot to deal with.SLIPYou have the correct solution, butexecute it upGroup IntegratedSafetyTrainingWorkshop: Human Factors9 ATSFederal AviationAdministration

CAUSES OF HUMAN ERRORWhy do we make IncidentAnalysisGroupGroup IntegratedSafetyTrainingWorkshop: Human Factors10 ATSFederal AviationAdministration

INTERNAL FACTORS: THE DIRTY DOZENLACK OFCOMMUNICATIONIssues around: Words PhrasesDISTRACTIONSInternal: You become bored,which causes your mindto wanderLACK OFRESOURCESLack of: SkillSTRESSAcute: Experience Caused by dealing withan emergency Knowledge Working under pressureChronic: Caused by long-termdemands, such as family,finances, or illnessExample:Using non-standardphraseology can causemiscommunication.Example:While bored, your mind canwander to more alysisGroupGroup IntegratedSafetyTrainingWorkshop: Human Factors11 ATSExample:A lack of any of the above caninterfere with your ability tocomplete a task.Example:Stress can affect yourjudgment and ability toconcentrate.Federal AviationAdministration

INTERNAL FACTORS: THE DIRTY DOZENCOMPLACENCYSome people think: They are perfectcontrollers They will never have anincidentLACK OFTEAMWORKKey teamwork skillsinclude: Effective communication TrustPRESSURECaused by: Lack of resources Inability to cope with asituationLACK OFAWARENESSTunnel visionmay result from: Stress Fatigue Pressure They are Teflon-coated DistractionExample:Overconfidence can lead tocomplacency.Example:No single person can beresponsible for the safeoutcomes of all p IntegratedSafetyTrainingWorkshop: Human Factors12 ATSExample:Pressure to maintainseparation can interfere withour ability to control traffic.Example:Not working as a team andonly considering one’s ownresponsibilities can lead totunnel vision.Federal AviationAdministration

INTERNAL FACTORS: THE DIRTY DOZENLACK OFKNOWLEDGECaused by: Not having theappropriate training Not knowing what youneed to know A bit shy to ask acoworker for helpExample:Systems and procedures canchange substantially, andcontrollers’ knowledge canquickly become out of date.FATIGUEFatigue: Can diminish your mentalcapacityLACK OFASSERTIVENESSExemplified by: Not asking for help Reluctance to expresssafety concern Result of needing sleepor physical restIncidentAnalysisATSIncidentAnalysisGroupGroup IntegratedSafetyTrainingWorkshop: Human Factors13 ATSEnforced throughpeers: Everyone in the facilitydoes it “that way” Often deviates fromproceduresTiredness:Example:After 2 hours on position, yourbrain is fatigued, but you arenot tired.NORMSExample:Being unable to expressconcerns causes ineffectivecommunication and damagesteamwork.Example:Most norms do not apply to allcircumstances.Federal AviationAdministration

EXTERNAL FACTORS Inadequate workspace or layoutPoor environmental conditionsInadequate human engineering designInadequate trainingTechnology changesTask or procedure changesCell phone distractionsATS Incident Analysis GroupFederal AviationAdministration

Seven vulnerabilities toHuman Information Processing Visual sampling/Selective Attention Information clutter Expectation Driven Processing Read back-Hear back Working Memory Information saturation Situation Awareness Predictive SA is dependent on spatial working memory to compute trajectories based on aircraftstate, intended plans, and aircraft dynamics Communications Effectiveness depends on shared assumptions (it’s a conversation) Long Term Memory Prospective memory, the bridge to future actions based on knowledge Judgment/Decision Making Agile memory built from knowledge based experience

ERRORS VS. AT-RISKBEHAVIORSATS Incident Analysis GroupFederal AviationAdministration

AT-RISK BEHAVIOR Group IntegratedSafetyTrainingWorkshop: Human Factors17 ATSFederal AviationAdministration

CONCLUSION Humans process information for meaning and toprioritize in order to complete the required task. Human error is inadvertently doing somethingother than what should have been done: amistake, lapse, or slip. We can lessen mistakes, lapses, or slips byrecognizing and mitigating internal and externalfactors that can lead to errors. At-risk behaviors occur when we choose not tofollow the rules.ATS Incident Analysis GroupFederal AviationAdministration

End-of-LessonATS Incident Analysis Group

Integrated Safety Training Workshop: Human Factors 4. Federal Aviation Administration . ATS Incident Analysis Group . Human Factors . cont. In the aviation industry, the science of human factors is dedicated to better understanding how humans can most safely and efficiently be integrated with technology.