1. Overcoming Human Factors by Retraining: What is Next for Crew Members After a Mishap Investigation? by Captain Paul Miller

2. Overcoming Human Factors by Retraining: What is Next for Crew Members After a Mishap Investigation? by Captain Paul Miller

3. Welcome to the 24th European Aviation Safety Seminar Dublin, Ireland February 29 - March 1, 2012

4. partnership between European Advisory Committee, Flight Safety Foundation Eurocontrol European Regions Airline Association partnership between European Advisory Committee, Flight Safety Foundation Eurocontrol European Regions Airline Association

5. Problem in a rhyme: What do you do, with members of the Flight Crew after the Boards are through? You are faced with the task Of how to renew What has unexpectedly gone askew? When assets are few, with no set course to pursue, what do you do?

6. Retraining is a clue that will work for you to plan a syllabus of human factors improoo improvement.

7. Problem: Good crew - remember that the company assigned them to the flight, as fully qualified, fully certified, fully competent, totally checked out when they began their assignment. [If they were “screwed up” as alleged, why were they assigned to operate the flight?]

8. Problem: Good crew HF particular & specific human error Possibly loss of certification by regulator No plan for recertification No plan for human factors retraining No plan tailored to this particular flight crew, who have this particular & specific HF problem

9. Problem: HF human error Possibly loss of certification by regulator No plan for recertification No plan for human factors retraining No plan tailored to this particular flightcrew, who have this particular & specific HF problem

10. Problem = Need: HF human error Possibly loss of certification by regulator No plan for recertification No plan for human factors retraining No plan tailored to this particular flightcrew, who have this particular & specific HF problem

11. Need: Plan for recertification Plan for human factors retraining Plan tailored to this particular flight crew, who have this particular & specific HF problem

12. Need: Plan for tailored HF retraining

13. Need: Plan for tailored HF retraining To prepare for recertification if needed

14. Why tailored HF retraining?

15. Why tailored HF retraining? Is it the same as recertification?

16. Why tailored HF retraining? Is it the same as recertification? [remember that this crew was certified at their current level of HF skill]

17. Why tailored HF retraining? Is it the same as recertification? [remember that this crew was certified at their current level of HF skill] Most likely the Mishap Investigation revealed “pilot error”

18. Why tailored HF retraining? Is it the same as recertification? [remember that this crew was certified at their current level of HF skill] Most likely the Mishap Investigation revealed “pilot error” that is, a human factors deficiency

19. Why Recertification may or may not include a human factors element

20. Why? Recertification may or may not include a human factors element But this crew achieved certification previously but did so without achieving or maintaining competency in HF skills

21. Why? therefore, the deficiency was in HF, not in certification Therefore, recertification alone will not address the HF deficiency.

22. Why? Even if dismissed from one company, the crew may get recertified and work for another company Still with the HF deficiency

23. Why? If not dismissed, the crew may get recertified and work for the same company But, …still with this particular & specific HF deficiency

24. Why? If not dismissed, the crew may get recertified and work for the same company But, …still with this particular & specific HF deficiency … another mishap waiting to happen?

25. Remember If charges of the regulatory administrative investigation are true… If the charges of the criminal investigatgion are true… If the charges of the accident investigation board are true….

26. Remember Then the airman/men had gained certification once already… Having done so with the current HF deficiencies...

27. Remember Therefore the airline policy of “dismiss and replace” And the regulatory policy of “sanction and recertify” May never address the human factors deficiency

28. Remember Therefore the airline policy of “dismiss and replace” And the regulatory policy of “sanction and recertify” May never address the human factors deficiency and is not a good solution.

29. Training is Learning We learn from our mistakes? Keep the mishap crew? Didn’t realize that they were making a human error Educate other flight crew to recognize the problem, take correct action, avoid a mishap

30. Accident vs Mishap Accident -event of chance -event outside of human control -uncertainty -probability Mishap -event of human action/inaction -linked directly to human behavior -preventable

31. Accident vs Mishap Accident -event of chance -event outside of human control -uncertainty -probability Mishap -event of human action/inaction -linked directly to human behavior -preventable

32. Accident vs Mishap Accident -event of chance -event outside of human control -uncertainty -probability Mishap -event of human action/inaction -linked directly to human behavior -preventable

33. Safety Style Mishap Investigation Finds: -Human factors -Human errors Recommends Changes: -prevent that error, that factor from being made by another crewmember again

34. Safety Theory As human errors are decreased… …the introduction of safety hazards are decreased

35. …Safety Theory As safety hazards are decreased … …mishaps will be decreased

36. Tailored Retraining Decrease human factors in commercial aviation by increased human factors training… …mishaps will be decreased towards zero in commercial aviation

37. Tailored Retraining derives from Safety Investigation only -not from a Legal accident board investigation -not from a Criminal and /or Civil Investigation -not from an Administrative Regulatory Certification Hearing -not from an FAA Part 709 Ride

38. Tailored Retraining derives from Safety Investigation only Seek cause of the mishap Offer recommended corrective actions that would have prevented this mishap

39. Legal Accident Board Investigations Seek evidentiary reasons to find blame for property damage and personal injury suffered Documents source for further litigation form compensation and punishment

40. Legal Accident Board Investigations Seldom recommend course of action for crew involved

41. Admin-Regulatory Certifications Airman Certificate -suspend -revoke -reinstate No course of action to prevent recurrence of mishaps

42. FAA Part 709 Rides Intended to weed out weak crew members and revoke certification Not intended to retrain crew who possess a HF weakness, such as in judgment

43. Human Factors Studies focus on frailties of… -judgment -decision making -behavior -communications skills -attitude -stress

44. Human Factors Studies focus on frailties of… -fatigue -loss of situational awareness -interpretation of data -crew resource management, working together well

45. Tailored Retraining focuses on how and why human frailties led to -failure to use already established standard operating procedures (SOP) -why, even with a very high level of compliance of SOP, some crew still do not comply at times

46. Tailored Retraining focuses on how and why -and even a few do not comply at all…. -except during check rides and training events

47. Tailored Retraining is able to reach through the thought process -For those few for whom normal training does not -improve their compliance with SOP -addressing HF, human error, pilot error specifically

48. Tailored Retraining is not -procedural recertification to reacquire airman certificates lost -regular training set up to build on basic skills developed in basic training

49. Linking Mishap Investigation to Tailored Retraining -Derived from finding of facts and analysis of crew errors causing the mishap, -Deviations from the normal procedures, practices and techniques.

50. Linking Mishap Investigation to Tailored Retraining -Conclusions, that if followed would have prevented mishap -Deviations from the normal procedures, practices and techniques.

51. Linking Mishap Investigation to Tailored Retraining -Clearly defined steps that will prevent the mishap from recurring -Adapts steps into custom tailored individualized HF retraining

52. Linking Mishap Investigation to Tailored Retraining -Adapting tailored retraining from non0mishap investigations is essentially the same -incidents, other hazardous events

53. Tailored Retraining Program Template 1. Deficiency evaluation 2. Standard Identification 3. Tailored Retraining

54. 1. Deficiency evaluation 1. Of the mishap aviator 2. Start with investigation finding of facts and analysis 3. Specific in nature to identify the problem

55. 1.1 Specific in nature to identify the problem a. HF deficiency serious? b. What exactly deficiency in concrete terms c. How exactly is it identified? d. How did the HF deficiency cause the mishap to occur?

56. 1.1 Specific in nature to identify the problem e. From conclusion, will eliminating the HF deficiency prevent the mishap? f. Direct demonstrable and direct cause-result logical relationship between HF hazard and the mishap?

57. 1.1 Specific in nature to identify the problem For example: is the pilot poor at flying go-arounds due to poor situational awareness?

58. 1.1 Specific in nature to identify the problem For example: is preflight planning inadequate due to poor communications skills?

59. 1.1 Specific in nature to identify the problem For example: is there a disregard for the SOP because of a belief that SOP only applies on checkrides, but not on line flights? If so, what section of SOP and to what consequence?

60. Very important Note: Do not mis-identify HF errors that might have occurred at the same time of the mishap, but which were not the cause of the mishap, as causal. Coincidence is not causal

61. 1.2. Deficiency Report Written formal report based on Mishap Investigation Report and other sources such as DFDR files

62. 1.3. Deficiency Report Endorsed by supervisor of flying or other appropriate authority to ensure training and ops concur on how to proceed

63. Step 2 of Design Template Standard is clearly spelled out and exact without ambiguity Is the standard in the SOP? Is it a practice taught by instructors? Is it a technique used on the line?

64. Step 2 of Design Template If the standard is a practice or technique, it will have to be written down as a “retraining procedure.”

65. Step 3 of Design Template Compare the deficiency with the standard and identify the difference From the difference design a retraining program to link the deficient aviator with the standard

66. Step 3 of Design Template Recommended recipe of action Simple methods to remember to do the correct action at the correct time

67. Step 3 of Design Template 3.1. Specific ground school, simulator and flight syllabus to guide training and ops dept 3.2. Formal Written Training Program with lesson plans, resource material, additional SOP and checklists

68. Step 3 of Design Template Additional scheduling, testing and academic expectations

69. Step 3 of Design Template 3.3. Endorsed by supervisor of flying so that there is no doubt that Tailored Retraining Program is an agreement of the highest order…

70. Step 3 of Design Template 3.3. …that must be completed by the mishap crew members in order to proceed with recertification if necessary and to line operations requalification.

71. Retraining flowing from practice and technique Will be written directives of the training department Will be identified as extra SOP for the crew undergoing Retraining.

72. Extra SOP will form a bridge Between the SOP and what everyone else up until this time understood to be normal human factors standards Exhibited by other line crew members

73. Extra SOP will form a bridge Will serve to fill in the deficiencies in HF by the mishap crew

74. Extra SOP will form a bridge For example: most crew will give a verbal take off brief from memory, with elements from the SOP Retraining crew will use written checklist as an extra SOP to ensure all areas are covered

75. Extra SOP will form a bridge Also to ensure that the rest of the crew fully understands, agrees and is prepared to do as planned

76. Extra SOP will form a bridge In one example a captain said, “Brief as standard.” After TO, conditions changed, crew was confused on what to do next, did not know the intentions of the other crew member, mishap occurred in confusion.

77. 4. Retraining is more than remedial basic skills training Develops extra SOP that will guide the crew to comply with the SOP

78. 4.1. Retraining is more than remedial basic skills training Example: SOP requires Wx brief before TO, enroute and LD, but may not specifiy procedural adjustments based on specific weather.

79. 4.1. Retraining is more than remedial basic skills training The norm for captains is to IMC, Convective WX make a briefing comment about avoidance, windshear recovery, alternate courses, holding, anti-icing and diverts.

80. 4.2. Retraining crew may need written convective wx SOP A checklist to make sure that all sections of the AOM and FOM are considered for line operations

81. 4.3. Retraining crew may need written convective wx SOP In one example a crew had a mishap due to a microburst encounter on landing.

82. 4.3. Retraining crew may need written convective wx SOP Retraining may provide an extra SOP and written checklist that will guide them clear of the convective weather rather than into an encounter, to hold or divert to a clear field.

83. 4.4. Retraining crew may need an extra written predeparture deicing SOP

84. -holdover times -engine run up times and intervals -snow depth clutter These items are often not found in one convenient place

85. 4.4. Retraining crew may need an extra written predeparture deicing SOP Maybe this aviator needs a special checklist and an extra SOP so that every item to be reveiwed prior to a cold, snowy, windy evening departure is in one place?

86. 4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight tool to ensure consistency and standardization when confronted with so many other factors, such as weather and ops tempo

87. 4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight Maybe this particular pilot needs the briefing checklist to reset thinking when stress factors distract, such as late departures, maintenance MEL issues

88. 4.5. Retraining crew may need extra SOP and a checklist for briefing each segment of flight Maybe this will ensure an excellent flight for this crew, despite various HF interferemce.

89. 4.6. Retraining must be specific in nature, for example judgment and coordination This crew needs to exercise judgment and coordination in extra HF training Difficult decisions practice, practice and more practice

90. 4.6. Retraining must be specific in nature, for example judgment and coordination if other HF areas are not deficient, then retraining must focus solely on the areas of deficiency for improvements.

91. Review: Tailored Retraining 1. Specific in nature to identify HF problem

92. Review: Tailored Retraining 2. Formal, written training program to guide retraining crew and instructors

93. Review: Tailored Retraining 3. Endorsed by the supervisor of flying or other appropriate authority to guide operations and training departments

94. At the completion of Tailored Retraining Retrained crew should be required to use the extra SOP and checklist for the foreseeable future

95. At the completion of Tailored Retraining Intention is for the retrained crew to assimilate the extra SOP into good practice and good technique and improved communications.

96. After completion of Tailored Retraining Other crew members might want a copy of the extra SOP and checklist Consideration incorporating into new SOP? Prevent future HF events?

97. Example of a HF mishap Air Florida 90, cold snowy departure Engine run up SOP? Holdover in SOP? Take off abort in SOP?

98. Example of a HF mishap Might a snowy departure SOP have helped? Might an erroneous EPR, Take off abort SOP have helped?

99. Example of a HF mishap What course of retraining on these subjects have helped to prevent other HF disasters?

100. Conclusion: Advantage of Retraining In lieu of regulatory admin certificate action Formal program to directly address HF deficiencies in training

101. Conclusion: Advantage of Retraining Formal program to take the recommended corrective actions of a mishap investigation and put them into training and procedures.

102. What is next for crew members after a mishap investigation? Tailored HF Retraining Program

103. Thank you More case studies at http://safetyforecast.com