Presented to: Orlando Florida Flying Community By: The FAASTeam - Dr. Karen D. Dunbar Date: December 7th, 2010 Federal Aviation Administration FAASTeam Orlando Florida Presentation Human Factors

2 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 What is a Pilot Deviation? A pilot deviation is defined as the actions of a pilot that result in the violation of a Federal Aviation Regulation or a North American Aerospace Defense (Command Air Defense Identification Zone) tolerance. FAA Order C.

3 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010

4 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 A Partial Listing of the Unsafe Acts of Operators Errors Decision Errors “Honest mistakes,” occur when one one does not have appropriate knowledge or made a poor choice, or procedural error.

5 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Decision Errors Improper inflight planning Improper altitude/clearance Aborted takeoff/landing decision improper Weather evaluation inadequate Improper refueling decisions Improper remedial action

6 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 A Partial Listing of the Unsafe Acts of Operators Errors Skill-based Errors “Stick and rudder” and other basic flight skills that occur without significant conscious thought. Vulnerable to failures of attention, memory and/or technique.

7 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Skill-based Errors Airspeed not maintained Aircraft control inadequate Abrupt vs. excessive vs. not maintained Stall spin inadvertent Altitude improper/not maintained Inadequate visual lookout Proper glide path not maintained

8 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 A Partial Listing of the Unsafe Acts of Operators Errors Perceptual Errors Errors due to erroneous response to illusions. Occur when sensory imput is degraded.

9 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Perceptual Errors Misjudged distance/Descent Misjudged altitude Misjudged maneuver/procedure Clearance not maintained Spatial disorientation/vertigo Visual Illusion

10 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 A Partial Listing of the Unsafe Acts of Operators Violations Routine Infractions “Bending” the rules tolerated by authority. Must look up the supervisory chain to identify those in authority who are not enforcing rules.

11 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Routine Infractions VFR flight into IMC (continued, performed, encountered) Flight into adverse weather continued IFR procedure not followed Procedures/directives not followed Minimum descent altitude not maintained Operation with known deficiency in equipment performed

12 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 A Partial Listing of the Unsafe Acts of Operators Violations Exceptional Infractions Isolated deviation from the rules, but not tolerated by management. Difficult to predict, since not indicative of one’s usual behavior.

13 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Exceptional Infractions Low altitude flight/buzzing performed Operation with known deficiency in equipment intentional VFR flight into IMC intentional Flight into adverse weather intentional Design stress limits of aircraft exceeded Aircraft weight and balance

14 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Preconditions for Unsafe Acts Substandard Conditions of Operators Adverse Mental States Mental conditions that affect performance

15 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Adverse Mental States Impairment – alcohol/drugs (can be OTC meds) Fatigue – lack of sleep, flight schedule Excessive workload Overconfidence in personal abilities Overconfidence in aircraft capabilities Complacency Diverted attention Circadian dysrhythmia/disruption Pressure induced by conditions/events

16 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Preconditions for Unsafe Acts Substandard Conditions of Operators Adverse Physiological States Medical/Physiological conditions that preclude safe operations

17 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Adverse Physiological States Spatial disorientation Impairment due to illness Incapacitation/loss of consciousness Physical impairment Hypoxia Motion sickness Illness

18 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Preconditions for Unsafe Acts Substandard Conditions of Operators Physical/Mental Limitations Situation exceeds the capabilities of the operator.

19 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Physical/Mental Limitations Lack of recent/total time Lack of recent/Total instrument time Visual look out not possible Physical impairment visual deficiency Lack of familiarity with geographical area Lack of familiarity with aircraft

20 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Preconditions for Unsafe Acts Substandard Practices of Operators Crew Resource Management Poor communication/coordination among personnel.

21 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Classification of CRM failures

22 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Crew Resource Management Preflight planning preparation inadequate Aircraft preflight inadequate Crew group coordination inadequate Poor communication/coordination within and between aircraft, ATC, etc. Failure of leadership

23 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Preconditions for Unsafe Acts Substandard Practices of Operators Personal Readiness Failure to prepare mentally or physically for duty.

24 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Personal Readiness Failure to adhere to crew rest requirements Self-medicating Overexertion while off duty Poor dietary practices Failure to adhere to bottle to brief rules

25 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Best Practice Session at the 2009 summit Brickey, R., Hubbartt, J., Vallee, C.

26 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Situation awareness Accuracy of a person’s current knowledge and understanding of task at hand and related working conditions compared to actual conditions at a given time

27 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Task preview S ummarize A nticipate F orsee E valuate R eview

28 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Task preview Job site preview

29 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Task preview Job site preview Questioning attitude

30 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Task preview Job site preview Questioning attitude Self-checking S top T hink A ct R eview

31 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Task preview Job site preview Questioning attitude Self-checking Procedure Use and Adherence

32 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Task preview Job Site preview Questioning attitude Self-checking Procedure Use and Adherence Effective Communication

33 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Practical Tools to Stop Worker Error Task preview Job site preview Questioning attitude Self-checking Procedure Use and Adherence Effective communication Phonetic alphabet

34 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 When is an error/deviation not a pilot error/deviation? When it is an ATC operational error or operational deviation.

35 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010 Bottom Line Human error is often preventable Adequate ability, attitude, training, skills, experience, planning, preparation, decision making, procedure adherence, communication, and self- and situational awareness will avoid most of the errors that lead to unsafe acts by pilots.

36 Federal Aviation Administration FAASTeam CFI Workshop 8 December 7, 2010