1. Human Factors for Part 135 Air Operators
Beyond Filling the Square

2. Human Factors and/or CRM Training?
Collings Foundation Pilot Groundschool
18-19 January 2012
Human Factors and/or CRM Training?
Who?
Where?
When?

3. 4/16/2017
Human Factors
A multidisciplinary field devoted to optimizing human performance and reducing human eror.
(OOOPS!)
Sun N Fun 2001

4. The study of human – machine interaction in context
Human Factors
The study of human – machine interaction in context

5. Collings Foundation Pilot Groundschool
18-19 January 2012
Ergonomics
Designing the machine and task to fit the human
(or not)

6. Quick CRM History 1940's - Military 1970's - Accident Studies/ ASRS
1980's - Pilot Judgment Training
1980's - Cockpit Resource Management
1990's - Crew Resource Management
2000's – Threat & Error Management
2010's - Same Stuff, Different Day

7. Lack of Accidents ≠ Safety!
Collings Foundation Pilot Groundschool
18-19 January 2012
Lack of Accidents ≠ Safety!
1 in 600

8. Margin of Safety vs. Accidents

9. Collings Foundation Pilot Groundschool
18-19 January 2012
Safety
The freedom from danger, risk, or injury.

10. 4/16/2017
It Won’t Happen To Me!
WHEN ANYONE ASKS ME HOW I CAN BEST DESCRIBE MY EXPERIENCE IN NEARLY FORTY YEARS AT SEA, I MERELY SAY, UNEVENTFUL. OF COURSE THERE HAVE BEEN WINTER GALES, AND STORMS AND FOG AND THE LIKE, BUT IN ALL MY EXPERIENCE I HAVE NEVER BEEN IN AN ACCIDENT OF ANY SORT WORTH SPEAKING ABOUT. I HAVE SEEN BUT ONE VESSEL IN DISTRESS IN ALL MY YEARS AT SEA....I NEVER SAW A SHIPWRECK AND HAVE NEVER BEEN SHIPWRECKED, NOR WAS I EVER IN ANY PREDICAMENT THAT THREATENED TO END IN DISASTER OF ANY SORT.
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Sun N Fun 2001

11. It Won’t Happen To Me!
ON 14 APRIL 1912 RMS TITANIC SANK WITH THE LOSS OF 1500 LIVES - ONE OF WHICH WAS IT’S CAPTAIN E.J. SMITH

12. It won’t happen to me…again?
Collings Foundation Pilot Groundschool
18-19 January 2012
It won’t happen to me…again?
Meanwhile, the Italian cruise operator said Capt. Francesco Schettino intentionally strayed from the ship's authorized course into waters too close to the perilous reef, causing it to crash late Friday and capsize.
The navigational version of a "fly by" was apparently made as a favor to the chief waiter who is from Giglio and whose parents live on the island, local media reported.
A judge on Tuesday is to decide whether Schettino should remain jailed.
"We are struck by the unscrupulousness of the reckless maneuver that the commander of the Costa Concordia made near the island of Giglio," prosecutor Francesco Verusio told reporters. "It was inexcusable."
The head of the U.N. agency on maritime safety said lessons must be learned from the Concordia disaster 100 years after the Titanic rammed into an iceberg, leading to the first international convention on sea safety.
"We should seriously consider the lessons to be learned and, if necessary, re-examine the regulations on the safety of large passenger ships in the light of the findings of the casualty investigation," said Koji Sekimizu, secretary-general of the International Maritime Organization.
What is certain is that, soon after the voyage began, passengers heard a bang and the ship was plunged into darkness. The first theory is based on the captain’s account of events – that he hit an uncharted rock and reacted by bringing the vessel into safer shallow waters off the island of Giglio. There it was damaged again on rocks and rolled on to its side.
Under International Maritime Organisation rules, captains are supposed to use the ship itself as a ‘lifeboat’ and return to port for evacuation.
The second is that there was a massive electrical failure which affected the ship’s navigation equipment, or a computer failure that sent the navigation systems haywire causing it to go too close to shore where it hit the rocks.
A third theory is that it was old-fashioned human error – or even recklessness – that allowed the vessel to ground in shallow waters. The investigation will look into every decision, order and event that led up to the sinking and will take months to come to a conclusion. On paper, human error remains the prime suspect.
It is the main cause of 80 per cent of shipping accidents and the crew may simply have become distracted or lost concentration early on in the voyage, allowing the vessel to drift to the coast.
Human error? Francesco Schettino, captain of the Costa Concordia, is taken into police custody on Saturday
However, the Electronic Chart Display Information System – a computer based system that uses GPS and mapping to pinpoint a vessel’s location – should have sounded an alarm the moment the ship left its course.
If it didn’t, then it suggests human error was compounded by a computer failure.
One clue to what happened lies in the reports of an explosion and the failure of the ship’s lights. That points to an electrical failure, perhaps caused by a power surge which led to a malfunction in the ship’s generators.
The ship is powered by a bank of diesel engines which generate electricity to turn the propellers and power lights and heating on board. The power surge could have led to an explosion in the engine room – causing the lights to fail, the engines to shut down and the steering to stop working.
If that happened close to shore, the ship could have run into rocks. The systems are designed to come back on, but it takes time, and there might not have been enough.
A similar failure hit the Queen Mary 2 in September 2010 as it approached Barcelona. On that occasion, there were no hazards nearby so there was no immediate danger and the engines were working again within half an hour.
Maritime safety expert Phil Anderson had experience of a power failure in the North Atlantic years ago on a cargo ship.
‘The chief engineer got to the engine room and restarted the engine – but it didn’t give us back the steering,’ he said. ‘So the engine went on and the revs started building up. The ship turned around sideways to the wind and waves, a highly dangerous position.’
Alternatively, maritime safety expert Alan Graveson believes the captain may have indeed have hit an uncharted rock as he claims, and although the ship would have had an echo sounder to detect unforeseen objects, the warning of approaching rocks could have come to late to do anything about it.
Uncharted rocks seem unlikely in busy waters off Italy. But there is a precedent.
In April 2007, a cruise ship called the Sea Diamond struck a reef in Greek waters and sank, killing two passengers. A survey later found that the reef was not charted correctly on official maps. Mr Graveson said: ‘If that’s what happened in this case the captain would have headed to land and might have hit more rocks as the ship approached the coast.’
A ship the size of the Costa Concordia is unable to float if water is less than 26ft deep – which explains why it so quickly turned on its side. But if it had sunk in deep water, hundreds could have died.
Whatever the cause, Mr Graveson believes the accident highlights a widespread problem with the new generation of massive cruise ships.
They may be more vulnerable when they take in water, and more likely to list. They are certainly tricky to steer. Crews complain that they are like trying to steer a block of flats and that they are vulnerable to side wind. They are also harder to evacuate. What little outdoor deck space is available becomes more and more crowded as extra storeys of cabins are added to the design.
And ironically – 100 years since Titanic – there are concerns about lifeboats. Andrew Linington, of the union Nautilus UK, said lifeboats on ships had barely moved on since 1912.
Boats are still lowered on wires and if the vessel is listing badly, half are unusable. In contrast, oil rigs already use escape capsules, or ‘free fall lifeboats’ – enclosed pods that drop into the water from a sloping ramp. They are quicker to use and do not need to be lowered on wires.
Experts stress, however, that despite the weekend’s shocking events, accidents remain rare.
From its humble beginnings as an Italian family firm, Costa has risen to become Europe’s top cruise operator. But it has been plagued by a history of accidents and scandal aboard its 15 ships.
One collision caused the deaths of three crew members, while a near-miss prompted an investigation into the company and its safety record.
And in 2008, the Costa Concordia hit the dockside in Palermo, Sicily, in bad weather, causing damage to the bow, though no one was hurt. It is not known whether the same captain was sailing it.
Crew members inspect the damage on the Costa Classica in Shanghai, after it collided with a Belgian cargo ship, Lowlands Longevity, whilst entering the port in October 2010
More seriously, the Costa Europa crashed in 2008 as its captain tried to dock at Sharm el-Sheikh in Egypt in high winds, killing three crew and injuring four passengers.
At the time, an unnamed maritime official blamed ‘100 per cent human error’, but Costa insisted bad weather was the cause. Later that year, power failure was blamed for the Costa Classica smashing into a cargo vessel in China’s Yangtze River, injuring three people.
The cruise line has also been plagued by reports of ineffective equipment and scandal.
In 2008, the Costa Atlantica developed steering problems. Separately, a crew member was arrested on a charge of possessing and importing child pornography.
The following year, the cruise line was fined £23,000 for deceptive advertising and there was a near-mutiny on the Costa Europa over engine problems.
There was also a fire on the Costa Romantica in the generator room which led to 1,429 passengers being evacuated.
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13. Primary Causal Factors of Aircraft Accidents
4/16/2017
Primary Causal Factors of Aircraft Accidents
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Sun N Fun 2001

14. CRM Requirement for Part 135

15. CRM
§ Crew resource management training. (a) Each certificate holder must have an approved crew resource management training program that includes initial and recurrent training. The training program must include at least the following:

16. CRM Authority of the pilot in command;
(2) Communication processes, decisions, and coordination, to include communication with Air Traffic Control, personnel performing flight locating and other operational functions, and passengers;
(3) Building and maintenance of a flight team;

17. CRM
(4) Workload and time management; (5) Situational awareness; (6) Effects of fatigue on performance, avoidance strategies and countermeasures; (7) Effects of stress and stress reduction strategies; and (8) Aeronautical decision-making and judgment training tailored to the operator's flight operations and aviation environment.

18. CRM
(b) After March 22, 2013, no certificate holder may use a person as a flightcrew member or flight attendant unless that person has completed approved crew resource management initial training with that certificate holder.

19. The “Roach Theory” of Errors
Collings Foundation Pilot Groundschool
18-19 January 2012
The “Roach Theory” of Errors
Errors are like roaches...
For every one you see...

20. “Threat and Error Management” (Dr. Robert Helmriech - U. of Texas)
4/16/2017
“Threat and Error Management” (Dr. Robert Helmriech - U. of Texas)
Studied crews (watched them)
Looked at “threats” and “errors”
Categorized types of threats and errors
Analyzed events to learn from them
Sun N Fun 2001

21. Latent Systemic Threats
4/16/2017
External Threats
Expected Threats
Forecast weather, terrain, fuel
Unexpected Threats
Mechanical problems, traffic, weather
Latent Systemic Threats
Accident waiting to happen
We've always done it this way
Sun N Fun 2001

22. What is “Human Error?”
Action or inaction that leads to a deviation from yours or someone else’s intentions or expectations.

23. Errors Are Like Roaches
Collings Foundation Pilot Groundschool
18-19 January 2012
Errors Are Like Roaches
There are different species and sizes
Slips - meant to do the right thing but took incorrect action
Lapses - omitted an item
Mistakes - intention was incorrect
Intentional Non-Compliance - intentionally deviated from SOP or accepted procedure

24. Error Enhancers
Fatigue/excessive stress
Lack of oxygen/water/food
Distractions/interruptions
“First learned, best learned”
Insufficient situation awareness
Workload -too low or high

25. Human Errors Leading To “Events”...
4/16/2017
Human Errors Leading To “Events”...
How many errors need to occur before we have an "event"?
Sun N Fun 2001

26. What is an “Event?”
The breaching, absence or bypassing of some or all of the aviation system’s various defenses and safeguards.

27. Collings Foundation Pilot Groundschool
18-19 January 2012
Here's the cheese...

28. Human Responses to Errors
4/16/2017
Human Responses to Errors
Trap - error is detected and managed before it becomes consequential
Exacerbate - error is detected but the individuals’ action or inaction becomes consequential
Fail to Respond - lack of a response to an error (undetected or ignored) that can either end up being inconsequential or consequential
Sun N Fun 2001

29. Error Management (aka) Roach Control
Collings Foundation Pilot Groundschool
18-19 January 2012
Error Management (aka) Roach Control
Detection and recovery
Understand and be vigilant for potential “error enhancers”
Prevent as many as possible
Oh Noooo...

30. Your Company Culture
The set of shared attitudes, values, goals, and practices that characterizes an institution or organization
The set of values, conventions, or social practices associated with a particular field, activity, or societal characteristic

31. Human Factors for Air Operators
Make Safety Your Culture