1. Presented to: By: Date: Federal Aviation Administration SSD 2013 Building a Safety Community

2. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Agenda 0700 – 0750 Breakfast and Registration 0750 – 0800 Welcome 0800 – 0930 FAA Information Session 0930 – 0945 Break 0945 – 1115 Introduction to Human Error 1115 – 1130 Break 1130 – 1300 Loss of Control Panel 1300 – Adjourn 2

3. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Welcome Exits Restrooms Emergency Evacuation Breaks Sponsor Acknowledgment Other information 3

4. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The Safety Stand Down Military Origins –Response to Safety Issue –Temporary Operations Halt –Devote time to Safety 4

5. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The Safety Stand Down Loss of Control –Still major factor in fatal accidents GA Joint Steering Committee –Safety Analysis Team Appch. & Ldg. LOC Workgroup –Findings & Recommendations »Technology »Human Factors 5

6. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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 6

7. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Rules of Engagement Audience questions/comments are welcome –Raise hand to be recognized Presenter will place you in cue –When you’re recognized: Please stand Speak so everyone can hear Wait for microphone to come to you 7

8. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration FAA Information Session Presented by: –Western Pacific Region –Los Angeles FSDO 8

9. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LAX FSDO Personnel Mr. Richard Falcon – FSDO Manager Ms. Cathy Lehman –Ops Unit Supervisor (Acting) Mr. James Magill –Airworthiness Unit Supervisor Mr. John Steuernagle –FAASTeam Program Manager 9

10. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 10 Van Nuys Riverside Long Beach

11. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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 11

12. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration FSDO Concerns Pilot Deviations Airborne TFR Violations Flight School Airworthiness Issues 12

13. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Contact us http://faa.gov Field & Regional Offices Flight Standards District Offices (FSDO) Select State Select Office 13

14. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Contact us http://faa.gov Field & Regional Offices Flight Standards District Offices (FSDO) Select State Select Office 14

15. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 15 Questions? John Steuernagle – FAASTeam Program Manager john.w.steuernagle@faa.gov (310) 725-6611 (Office) or (301) 471-3954 (Cell) LAX FSDO 15000 Aviation Blvd Hawthorne, CA (310) 725-6600

16. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Want Wings? 3 Knowledge Credits for this Stand Down –Preregistered? Initial roster –Not Preregistered? Sign in with legible faasafety.gov email 3 Flight Credits –With your CFI No Account? –See a Rep today 16

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21. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration What about mechanics? 21

22. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 22

23. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 23

24. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Introduction to Human Error Presented by: –Your Presenter Here 24

25. Federal Aviation Administration Human Error Making Sense of Accident Reports Presented to: FAASTeam 2013 Safety Stand Down 25

26. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Overview Error Fundamentals System aspects of error Application of Error Fundamentals Gold Seal Key Concepts SSD 2013 26

27. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration A.Human B.Universal C.Inevitable D.A bad thing To Err is: 27

28. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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. 28

29. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The 5 Ws Who What When Where Why 29

30. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The 6th W Who What When Where Why What’s to be done about it? 30

31. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Four questions are easy Who What When Where Why What’s to be done about it? 31

32. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The Accident Report Who What When Where Probable Cause Safety Recommendation 32

33. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The Accident Report Who What When Where Moose on Field Moose proof fence 33

34. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Hindsight Bias Hindsight Outside Violation Breakdown Lost the Bubble Failure Error Bad Judgment Incident Evolution Time (Sidney Dekker 2006) 34

35. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Incident Evolution Time Inside -Easy -Profitable -Loyalty -Prod- uctive -Flexible -Common Sense -Better -Skill -Creative -Perfect -Good Idea -Judgment -Experience -Best Option -Quick (Sidney Dekker 2006) Hindsight Bias 35 SSD 2013

36. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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 36

37. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration People cannot easily avoid those actions they did not intend to commit James Reason & Alan Hobbs (2003) SSD 2013 37

38. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration People cannot easily avoid those actions they did not intend to commit James Reason & Alan Hobbs (2003) Blaming people for their errors is emotionally satisfying but remedially useless. We’re still accountable for our mistakes though. 38

39. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Mikey’s story Late night with interrupted sleep Altered routine Preoccupation with work How big an error? –Consequence was huge –Error was common 39

40. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration People cannot easily avoid those actions they did not intend to commit SSD 2013 We all operate within systems Sometimes without knowing it 40

41. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia DeathsDeaths 41

42. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia DeathsDeaths 42

43. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia DeathsDeaths 38 43

44. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Accident Chain of Events 44

45. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Accident Chain of Events 45

46. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Accident Chain Unsafe Acts Preconditions Cultural Influences 46

47. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Unsafe Acts Cultural Influences Preconditions Leaving Mikey in car 47

48. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Pre-conditions Cultural Influences Pax side airbag Fatigue Warm Weather Preoccupation Leaving Mikey in car Sleeping Child 48

49. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Cultural Influences Child care responsibility Work ethic Pax side airbag Fatigue Sleeping Child Warm Weather Preoccupation Leaving Mikey in car 49

50. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Child care responsibility Work ethic Pax side airbag Fatigue Warm Weather Preoccupation Safety significant errors can occur at all levels of the system Leaving Mikey in car Sleeping Child 50

51. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The Swamp Unsafe Acts Preconditions Cultural Influences Adapted from Reason (1990) 51

52. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Adapted from Reason (1990) Coming Soon Bayou Junction Housing Development Unsafe Acts Preconditions Cultural Influences 52

53. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration People Structure/Organization Technology Tasks The General Aviation System 53

54. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 2000 1950 1960 1970 1980 1990 U.S. General Aviation Source NTSB 0 10 20 30 40 50 60 Accidents/100,000 flight hours Accidents=Approximately 7/100,000hrs Fatal Accidents=Approximately 2/100,000hrs 54

55. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Human Error is Both Universal and Inevitable It is the Downside of Having a Brain James Reason & Alan Hobbs (2003) SSD 2013 55

56. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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. James Reason & Alan Hobbs (2003) 56

57. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Conscious Workspace Long-term Memory General Problem Solver Limited Capacity Contents Available Sequential Processing Slow and Laborious Essential for new Tasks Vast Collection of Programs No Limits to Size or Duration Unconscious Parallel Processing Rapid and Effortless Handles Familiar Routines and Habits James Reason & Alan Hobbs (2003) Trial and ErrorProgramming 57

58. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration A C B C B A Conscious Work Space 58

59. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Long-term Memory 2 + 2 = ….. knock knock “...................?” Mary had.................. The sky is …….. Grass is ….. 59

60. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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 60 SSD 2013

61. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Count the F’s FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF MANY YEARS 61

62. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Count the F’s FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF MANY YEARS 62 3?

63. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Count the F’s FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF MANY YEARS 63 3 or 6?

64. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Choice Point needing conscious attention New Path Wrong Path Taken Usual Onward Path Skill-based Slip Highly Routine Sequence 64

65. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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 Education From: Home To: Work 65

66. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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. 66

67. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Error/Environment Logging Log errors by date Describe environment Include health, fatigue, stress Look for patterns 67

68. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Stress Walking the line $ 6 In. 8 In. 20 Ft. 68

69. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Stress Walking the line 69

70. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Extreme Stress Makes You Stupid 70

71. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Managing the Managable 2 hour flight @ 10 gph. = 20 gal. + 1 hour reserve = 30 gal. Fuel on board = 25 gal. 71

72. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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 72

73. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration A.What? B.Why? C.When? D.What’s to be done about it? The Ws that are hardest to answer are: 73

74. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration A.PCs but not MACs B.Conscious Workspace C.Long Term Memory D.MACs but not PCs Programming is an attribute of: 74

75. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration A.NTSB & FAA Investigations B.Central Nervous System C.Long Term Memory D.Conscious Workspace “Trial and Error” is an attribute of: 75

76. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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 …… 76

77. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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.” 77

78. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration If the flight’s not conforming to the plan ….. SSD 2013 78 It doesn’t pay to wait for things to get better. Address small problems early Before they become big ones

79. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Errors are not intrinsically bad We are “hardwired” to make errors Bad News Good News James Reason & Alan Hobbs (2003) 79

80. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The Recipe for Disaster Human Error + Unforgiving Activity= Disaster 80 James Reason & Alan Hobbs (2003)

81. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration James Reason & Alan Hobbs (2003) 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) 81

82. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration How many people? 82

83. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration or this one ….. ? 83

84. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 583 fatalities – 64 survivors Tenerife 27 March 1977 The Best People Tend to Make the Worst Mistakes SSD 2013 84

85. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration James Reason & Alan Hobbs (2003) Many Errors Fall into Recurrent Patterns 85

86. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration One More Thing Confirmation Bias 86

87. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration One More Thing Confirmation Bias You Common-sense Consistent Capable Correct Coherent Clever Other Drivers IgnorantInept IdiotIncompetent ImpoliteIll-mannered Fundamental Attribution Bias James Reason & Alan Hobbs (2003) 87

88. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration People cannot easily avoid those actions they did not intend to commit James Reason & Alan Hobbs (2003) SSD 2013 You can’t understand why accidents happen if you assume the pilots involved were idiots. 88

89. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration A.Confirmation? B.Hindsight? C.Plan Continuation? D.Fundamental Attribution? The human biases that may negatively influence accident investigations are: 89

90. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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: 90

91. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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: 91

92. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration A.Should be avoided B.Improve performance C.Inhibit performance D.Require medication Moderate stress levels: 92

93. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 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. 93

94. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Up next: 94

95. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Reading List Managing Maintenance Error –James Reason and Alan Hobbs Set Phasers on Stun and The Atomic Chef –Steven Casey Understanding Human Error –Sidney Decker Deep Survival –Laurence Gonzales The Limits of Expertise –Key Dismukes Sway –Brafman & Brafman 95

96. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Loss of Control Panel 96 Moderated by: –Your Moderator Here

97. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Loss of Control Panelists Ms. Erika Rauchundspiegel – Flight Instructor Mr. Ace Odabase –Airshow Pilot Mr. Al Goodwrench –AW ASI Dr. Frieda Gesundheit – Aviation.Medical Examiner Ms Hilda Sicherheit –FAASTeam Program Manager 97

98. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Fatal LOC Accidents 2001-2010 98

99. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration The PAVE Checklist Pilot Aircraft enVironment External Pressure (s) 99

100. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LOC Panel Case Study Number 1 100 Pilot –Private Pilot –Total Time ……319 –Time in type …. 1 Aircraft –Jodel D-9

101. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LOC Panel Case Study Number 1 101 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

102. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 102

103. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Discussion 103

104. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LOC Panel Case Study Number 2 104 Pilot –Private Pilot –Total Time ……604 –Time in type ….248 Aircraft –Cirrus SR 22

105. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LOC Panel Case Study Number 2 105 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

106. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 106 310@11, G22

107. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LOC Panel Case Study Number 2 107 Parachute –Deployed, but not fully extracted. Autopsy Findings –Diphenhydramine –Pseudoephedrine –Zolpidem

108. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Discussion 108

109. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LOC Panel Case Study Number 3 109 Pilot –Private Pilot –Total Time ……975 –Time in type ….44 Aircraft –TBM 700

110. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LOC Panel Case Study Number 3 110 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

111. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 111

112. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration LOC Panel Case Study Number 3 112 Autopsy Findings –Alfuzosin Prostate –Bisoprolol * Beta blocker –Quinine Arthritis –Tramadol For moderate to severe pain * Known to AME

113. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Discussion 113

114. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration Dedication Neil Armstrong 1930 - 2012 114

115. Safety Stand Down 2013 13 April 2013 Federal Aviation Administration 115 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